Patent Foramen Ovale and Cryptogenic Stroke: Challenges in Diagnosis and Management
Tantangan dalam Diagnosis dan Manajemen
Keywords:
Patent Foramen Ovale, Cryptogenic Stroke, Paradoxical Embolism, Echocardiography, Device Closure
Abstract
A patent foramen ovale (PFO) is a common disorder that affects between 20-34% of the adult population. This condition is a benign finding for most people. However, In some the PFO can open widely and enabling paradoxical embolism to transit from venous to arterial circulation, which is associated with stroke and systemic embolization. There are still unclear to date regarding the effectiveness of pharmacological anticoagulant therapy, defined as antithrombin or antiplatelet therapy, which has proven to be more beneficial for patients with PFO and cryptogenic stroke. In addition, surgical and transcutaneous PFO closure has been proposed for secondary prevention of stroke in patients with cryptogenic stroke with PFO. Both catheter-based and surgical modes of closure have been shown to reduce the incidence of subsequent embolism substantially. This review will discuss the evidence regarding the relationship between PFO and cryptogenic stroke and decision making for management strategies.
Downloads
Download data is not yet available.
References
1. Connuck D, Sun JP, Super DM, Kirchner HL, Fradley LG, Harcar-Sevcik RA, Salvator A, Singer L, Mehta SK. Incidence of patent ductus arteriosus and patent foramen ovale in normal infants. Am J Cardiol. 2002;89:244-247.
2. Hampton T, Alsaleem M, Murphy-Lavoie HM. Patent Foramen Ovale. [Updated 2021 Mar 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493151/?report=classic.
3. Giblett JP, Abdul-Samad O, Shapiro LM, Rana BS, Calvert PA. Patent foramen ovale closure in 2019. Interv Cardiol Rev. 2019;14:34-41.
4. Saver JL, Mattle HP, Thaler D. Patent foramen ovale closure versus medical therapy for cryptogenic ischemic stroke a topical review. Stroke. 2018;49:1541-1548.
5. Abdelghani M, El-Shedoudy SAO, Nassif M, Bouma BJ, De Winter RJ. Management of Patients with Patent Foramen Ovale and Cryptogenic Stroke: An Update. Cardiol. 2019;143:62-72.
6. Cramer SC, Rordorf G, Maki JH, Kramer LA, Grotta JC, Burgin WS, Hinchey JA, Benesch C, Furie KL, Lutsep HL, Kelly E, Longstreth WTJ. Increased pelvic vein thrombi in cryptogenic stroke: results of the Paradoxical Emboli from Large Veins in Ischemic Stroke (PELVIS) study. Stroke. 2004;35:46-50.
7. Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M, Drobinski G, Thomas D, Grosgogeat Y. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med. 1988;318:1148-1152.
8. Lamy C, Giannesini C, Zuber M, Arquizan C, Meder JF, Trystram D, Coste J, Mas JL. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial Septal Aneurysm. Stroke. 2002;33:706-711.
9. Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med. 2001;345:1740-1746.
10. Karttunen V, Hiltunen L, Rasi V, Vahtera E, Hillbom M. Factor V Leiden and prothrombin gene mutation may predispose to paradoxical embolism in subjects with patent foramen ovale. Blood Coagul fibrinolysis an Int J Haemost Thromb. 2003;14:261-268.
11. Lichy C, Reuner KH, Buggle F, Litfin F, Rickmann H, Kunze A, Brandt T, Grau A. Prothrombin G20210A mutation, but not factor V Leiden, is a risk factor in patients with persistent foramen ovale and otherwise unexplained cerebral ischemia. Cerebrovasc Dis. 2003;16:83-87.
12. Botto N, Spadoni I, Giusti S, Ait-Ali L, Sicari R, Andreassi MG. Prothrombotic mutations as risk factors for cryptogenic ischemic cerebrovascular events in young subjects with patent foramen ovale. Stroke. 2007;38:2070-2073.
13. Belvís R, Santamaría A, Martí-Fàbregas J, Leta RG, Cocho D, Borrell M, Fontcuberta J, Martí-Vilalta JL. Patent foramen ovale and prothrombotic markers in young stroke patients. Blood Coagul fibrinolysis an Int J Haemost Thromb. 2007;18:537-542.
14. Di Tullio MR, Homma S. Patent foramen ovale and stroke: What should be done? Curr Opin Hematol. 2009;16:391-396.
15. Hara H, Virmani R, Ladich E, Mackey-Bojack S, Titus J, Reisman M, Gray W, Nakamura M, Mooney M, Poulose A, Schwartz RS. Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol. 2005;46:1768-1776.
16. Cheng TO. Platypnea-orthodeoxia syndrome: etiology, differential diagnosis, and management. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 1999;47:64-66.
17. Cheng TO. Transcatheter closure of patent foramen ovale: a definitive treatment for platypnea-orthodeoxia. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2000;51:120.
18. Wilmshurst PT, Ellis BG, Jenkins BS. Paradoxical gas embolism in a scuba diver with an atrial septal defect. Br Med J (Clin Res Ed). 1986;293:1277.
19. Torti SR, Billinger M, Schwerzmann M, Vogel R, Zbinden R, Windecker S, Seiler C. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J. 2004;25:1014-1020.
20. Cartoni D, De Castro S, Valente G, Costanzo C, Pelliccia A, Beni S, Di Angelantonio E, Papetti F, Vitali Serdoz L, Fedele F. Identification of professional scuba divers with patent foramen ovale at risk for decompression illness. Am J Cardiol. 2004;94:270-273.
21. Morandi E, Anzola GP, Angeli S, Melzi G, Onorato E. Transcatheter closure of patent foramen ovale: a new migraine treatment? J Interv Cardiol. 2003;16:39-42.
22. Reisman M, Christofferson RD, Jesurum J, Olsen J V, Spencer MP, Krabill KA, Diehl L, Aurora S, Gray WA. Migraine headache relief after transcatheter closure of patent foramen ovale. J Am Coll Cardiol. 2005;45:493-495.
23. Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R. Association of interatrial shunts and migraine headaches: Impact of transcatheter closure. J Am Coll Cardiol. 2005;45:489-492.
24. Wilmshurst P, Nightingale S. Relationship between migraine and cardiac and pulmonary right-to-left shunts. Clin Sci (Lond). 2001;100:215-220.
25. Borgdorff P, Tangelder GJ. Migraine: Possible Role of Shear-Induced Platelet Aggregation With Serotonin Release. Headache J Head Face Pain. 2012;52:1298-1318.
26. Grotemeyer K-H, Scharafinski H-W, Schlake H-P, Husstedt IW. Acetylsalicylic Acid vs. Metoprolol in Migraine Prophylaxis - A Double-Blind Cross-Over Study. Headache J Head Face Pain. 1990;30:639-641.
27. Yuan K, Kasner SE. Patent foramen ovale and cryptogenic stroke: Diagnosis and updates in secondary stroke prevention. Stroke Vasc Neurol. 2018;3:84-91.
28. Understanding Diagnosis and Treatment of Cryptogenic Stroke : A Health Care Professional Guide. Am Stroke Assoc. 2015:24.
29. Kent DM, Ruthazer R, Weimar C, Mas J-L, Serena J, Homma S, Di Angelantonio E, Di Tullio MR, Lutz JS, Elkind MS V, Griffith J, Jaigobin C, Mattle HP, Michel P, Mono M-L, Nedeltchev K, Papetti F, Thaler DE. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology. 2013;81:619-625.
30. Pristipino C, Sievert H, D’Ascenzo F, Louis Mas J, Meier B, Scacciatella P, et al. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eur Heart J. 2019;40:3182-3195.
31. Prefasi D, Martínez-Sánchez P, Fuentes B, Díez-Tejedor E. The utility of the RoPE score in cryptogenic stroke patients ≤50 years in predicting a stroke-related patent foramen ovale. Int J stroke Off J Int Stroke Soc. 2016;11:NP7-8.
32. Wessler BS, Kent DM, Thaler DE, Ruthazer R, Lutz JS, Serena J. The RoPE Score and Right-to-Left Shunt Severity by Transcranial Doppler in the CODICIA Study. Cerebrovasc Dis. 2015;40:52-58.
33. Braemswig TB, Usnich T, Scheitz JF, Erdur H, Fiebach JB, Audebert HJ, Endres M, Nolte CH. Early Recurrent Ischemic Lesions in Patients With Cryptogenic Stroke and Patent Foramen Ovale: An Observational Study. Front Neurol. 2018;9:996.
34. Thaler DE, Ruthazer R, Weimar C, Mas J-L, Serena J, Di Angelantonio E, Papetti F, Homma S, Mattle HP, Nedeltchev K, Mono M-L, Jaigobin C, Michel P, Elkind MS V, Di Tullio MR, Lutz JS, Griffith J, Kent DM. Recurrent stroke predictors differ in medically treated patients with pathogenic vs. other PFOs. Neurology. 2014;83:221-226.
35. Yaghi S, Elkind MS V. Cryptogenic stroke: A diagnostic challenge. Neurol Clin Pract. 2014;4:386-393.
36. Kang D-W, Chalela JA, Ezzeddine MA, Warach S. Association of ischemic lesion patterns on early diffusion-weighted imaging with TOAST stroke subtypes. Arch Neurol. 2003;60:1730-1734.
37. Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation. 2002;105:2625-2631.
38. Mas J-L, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, et al. Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med. 2017;377:1011-1021.
2. Hampton T, Alsaleem M, Murphy-Lavoie HM. Patent Foramen Ovale. [Updated 2021 Mar 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493151/?report=classic.
3. Giblett JP, Abdul-Samad O, Shapiro LM, Rana BS, Calvert PA. Patent foramen ovale closure in 2019. Interv Cardiol Rev. 2019;14:34-41.
4. Saver JL, Mattle HP, Thaler D. Patent foramen ovale closure versus medical therapy for cryptogenic ischemic stroke a topical review. Stroke. 2018;49:1541-1548.
5. Abdelghani M, El-Shedoudy SAO, Nassif M, Bouma BJ, De Winter RJ. Management of Patients with Patent Foramen Ovale and Cryptogenic Stroke: An Update. Cardiol. 2019;143:62-72.
6. Cramer SC, Rordorf G, Maki JH, Kramer LA, Grotta JC, Burgin WS, Hinchey JA, Benesch C, Furie KL, Lutsep HL, Kelly E, Longstreth WTJ. Increased pelvic vein thrombi in cryptogenic stroke: results of the Paradoxical Emboli from Large Veins in Ischemic Stroke (PELVIS) study. Stroke. 2004;35:46-50.
7. Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M, Drobinski G, Thomas D, Grosgogeat Y. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med. 1988;318:1148-1152.
8. Lamy C, Giannesini C, Zuber M, Arquizan C, Meder JF, Trystram D, Coste J, Mas JL. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial Septal Aneurysm. Stroke. 2002;33:706-711.
9. Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med. 2001;345:1740-1746.
10. Karttunen V, Hiltunen L, Rasi V, Vahtera E, Hillbom M. Factor V Leiden and prothrombin gene mutation may predispose to paradoxical embolism in subjects with patent foramen ovale. Blood Coagul fibrinolysis an Int J Haemost Thromb. 2003;14:261-268.
11. Lichy C, Reuner KH, Buggle F, Litfin F, Rickmann H, Kunze A, Brandt T, Grau A. Prothrombin G20210A mutation, but not factor V Leiden, is a risk factor in patients with persistent foramen ovale and otherwise unexplained cerebral ischemia. Cerebrovasc Dis. 2003;16:83-87.
12. Botto N, Spadoni I, Giusti S, Ait-Ali L, Sicari R, Andreassi MG. Prothrombotic mutations as risk factors for cryptogenic ischemic cerebrovascular events in young subjects with patent foramen ovale. Stroke. 2007;38:2070-2073.
13. Belvís R, Santamaría A, Martí-Fàbregas J, Leta RG, Cocho D, Borrell M, Fontcuberta J, Martí-Vilalta JL. Patent foramen ovale and prothrombotic markers in young stroke patients. Blood Coagul fibrinolysis an Int J Haemost Thromb. 2007;18:537-542.
14. Di Tullio MR, Homma S. Patent foramen ovale and stroke: What should be done? Curr Opin Hematol. 2009;16:391-396.
15. Hara H, Virmani R, Ladich E, Mackey-Bojack S, Titus J, Reisman M, Gray W, Nakamura M, Mooney M, Poulose A, Schwartz RS. Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol. 2005;46:1768-1776.
16. Cheng TO. Platypnea-orthodeoxia syndrome: etiology, differential diagnosis, and management. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 1999;47:64-66.
17. Cheng TO. Transcatheter closure of patent foramen ovale: a definitive treatment for platypnea-orthodeoxia. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2000;51:120.
18. Wilmshurst PT, Ellis BG, Jenkins BS. Paradoxical gas embolism in a scuba diver with an atrial septal defect. Br Med J (Clin Res Ed). 1986;293:1277.
19. Torti SR, Billinger M, Schwerzmann M, Vogel R, Zbinden R, Windecker S, Seiler C. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J. 2004;25:1014-1020.
20. Cartoni D, De Castro S, Valente G, Costanzo C, Pelliccia A, Beni S, Di Angelantonio E, Papetti F, Vitali Serdoz L, Fedele F. Identification of professional scuba divers with patent foramen ovale at risk for decompression illness. Am J Cardiol. 2004;94:270-273.
21. Morandi E, Anzola GP, Angeli S, Melzi G, Onorato E. Transcatheter closure of patent foramen ovale: a new migraine treatment? J Interv Cardiol. 2003;16:39-42.
22. Reisman M, Christofferson RD, Jesurum J, Olsen J V, Spencer MP, Krabill KA, Diehl L, Aurora S, Gray WA. Migraine headache relief after transcatheter closure of patent foramen ovale. J Am Coll Cardiol. 2005;45:493-495.
23. Azarbal B, Tobis J, Suh W, Chan V, Dao C, Gaster R. Association of interatrial shunts and migraine headaches: Impact of transcatheter closure. J Am Coll Cardiol. 2005;45:489-492.
24. Wilmshurst P, Nightingale S. Relationship between migraine and cardiac and pulmonary right-to-left shunts. Clin Sci (Lond). 2001;100:215-220.
25. Borgdorff P, Tangelder GJ. Migraine: Possible Role of Shear-Induced Platelet Aggregation With Serotonin Release. Headache J Head Face Pain. 2012;52:1298-1318.
26. Grotemeyer K-H, Scharafinski H-W, Schlake H-P, Husstedt IW. Acetylsalicylic Acid vs. Metoprolol in Migraine Prophylaxis - A Double-Blind Cross-Over Study. Headache J Head Face Pain. 1990;30:639-641.
27. Yuan K, Kasner SE. Patent foramen ovale and cryptogenic stroke: Diagnosis and updates in secondary stroke prevention. Stroke Vasc Neurol. 2018;3:84-91.
28. Understanding Diagnosis and Treatment of Cryptogenic Stroke : A Health Care Professional Guide. Am Stroke Assoc. 2015:24.
29. Kent DM, Ruthazer R, Weimar C, Mas J-L, Serena J, Homma S, Di Angelantonio E, Di Tullio MR, Lutz JS, Elkind MS V, Griffith J, Jaigobin C, Mattle HP, Michel P, Mono M-L, Nedeltchev K, Papetti F, Thaler DE. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology. 2013;81:619-625.
30. Pristipino C, Sievert H, D’Ascenzo F, Louis Mas J, Meier B, Scacciatella P, et al. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eur Heart J. 2019;40:3182-3195.
31. Prefasi D, Martínez-Sánchez P, Fuentes B, Díez-Tejedor E. The utility of the RoPE score in cryptogenic stroke patients ≤50 years in predicting a stroke-related patent foramen ovale. Int J stroke Off J Int Stroke Soc. 2016;11:NP7-8.
32. Wessler BS, Kent DM, Thaler DE, Ruthazer R, Lutz JS, Serena J. The RoPE Score and Right-to-Left Shunt Severity by Transcranial Doppler in the CODICIA Study. Cerebrovasc Dis. 2015;40:52-58.
33. Braemswig TB, Usnich T, Scheitz JF, Erdur H, Fiebach JB, Audebert HJ, Endres M, Nolte CH. Early Recurrent Ischemic Lesions in Patients With Cryptogenic Stroke and Patent Foramen Ovale: An Observational Study. Front Neurol. 2018;9:996.
34. Thaler DE, Ruthazer R, Weimar C, Mas J-L, Serena J, Di Angelantonio E, Papetti F, Homma S, Mattle HP, Nedeltchev K, Mono M-L, Jaigobin C, Michel P, Elkind MS V, Di Tullio MR, Lutz JS, Griffith J, Kent DM. Recurrent stroke predictors differ in medically treated patients with pathogenic vs. other PFOs. Neurology. 2014;83:221-226.
35. Yaghi S, Elkind MS V. Cryptogenic stroke: A diagnostic challenge. Neurol Clin Pract. 2014;4:386-393.
36. Kang D-W, Chalela JA, Ezzeddine MA, Warach S. Association of ischemic lesion patterns on early diffusion-weighted imaging with TOAST stroke subtypes. Arch Neurol. 2003;60:1730-1734.
37. Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation. 2002;105:2625-2631.
38. Mas J-L, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, et al. Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med. 2017;377:1011-1021.
Published
2021-09-16
Views & Downloads
Abstract views: 3984
PDF downloads: 2024
PDF downloads: 2024
How to Cite
Yafi, D., & Azmi, A. (2021). Patent Foramen Ovale and Cryptogenic Stroke: Challenges in Diagnosis and Management. Indonesian Journal of Cardiology, 42(3). https://doi.org/10.30701/ijc.1144
Section
Review Article
Copyright (c) 2021 Indonesian Journal of Cardiology
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
