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Stroke Recurrence and its Prevention in Patients with Patent Foramen Ovale

Published online by Cambridge University Press:  02 December 2014

J. U. Harrer ,
T. Wessels ,
A. Franke ,
S. Lucas ,
P. Berlit  and
C. Klötzsch
J. U. Harrer*
Affiliation:
Department of Neurology, Aachen University Hospital, Aachen, Germany
T. Wessels
Affiliation:
Department of Neurology, Justus-Liebig-University, Giessen, Germany
A. Franke
Affiliation:
Department of Cardiology, Medical Clinic I, Aachen University Hospital, Aachen, Germany
S. Lucas
Affiliation:
Department of Neurology, Aachen University Hospital, Aachen, Germany
P. Berlit
Affiliation:
Department of Neurology, Alfried Krupp Hospital, Essen, Germany
C. Klötzsch
Affiliation:
Department of Neurology, Aachen University Hospital, Aachen, Germany Kliniken Schmieder Allensbach/Hegau Klinikum Singen, Germany
*
Department of Neurology, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany.
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Abstract:

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Background:

It is unclear whether medical or invasive (surgical or catheter interventional) treatment is preferable to prevent recurrence of cerebral ischemia in patients with patent foramen ovale (PFO) as the suspected cause of stroke and what the role of concomitant risk factors is in stroke recurrence.

Methods:

Over a period of ten years, 124 patients (mean age 51 ± 15 years) with cryptogenic cerebral ischemia and PFO were included into the study and prospectively followed over a mean of 52 ± 32 months. Of these, 83 were treated medically, 34 underwent transcatheter closure, and seven had surgical closure of the foramen. Of the medically treated patients, 11 stopped medication during follow-up. Recurrent ischemic events and risk factors for recurrence were analyzed.

Results:

Annual stroke recurrence rates were generally low and comparable in catheter and medically treated patients, and in patients who had stopped medication (2.9%/2.1%/2.2%/year). Patients suffering from recurrence after transcatheter closure (n=2) both had residual shunts. No stroke recurrence was observed in the few surgically treated patients. An atrial septal aneurysm was not a predictor of recurrent or multiple strokes (p>0.05, OR=0.31, and OR=0.74). Large shunts and a history of previous ischemic events were considerably more frequent in patients with recurrent strokes (p<0.05, OR=5.0, and OR=4.4). Pulmonary embolism and case fatality rates were significantly higher in patients with stroke recurrence (p<0.001, and p<0.01).

Conclusions:

The absolute risk of recurrent cerebrovascular events in patients with PFO receiving medical or catheter interventional therapy is low. The small group of untreated patients had a comparably low rate of stroke recurrences. Previous ischemic events and shunt size were risk factors in this observational study. Given conflicting findings across multiple studies, enrollment into a randomized controlled trial would be the optimal choice.

Résumé

RÉSUMÉ Contexte:

On ignore si le traitement médical ou le traitement effractif est préférable pour prévenir la récidive de l'ischémie cérébrale chez les patients porteurs d'un foramen ovale perméable (FOP) qu'on soupçonne être la cause d'un accident vasculaire cérébral (AVC) et quel rôle jouent les facteurs de risque concomitants dans la récidive de l'AVC.

Méthodes:

Cent vingt-quatre patients porteurs d'un FOP et ayant présenté une ischémie cérébrale cryptogénique ont été recrutés de façon prospective sur une période de 10 ans (âge moyen 51 ± 15 ans) et suivis pendant 52 ± 32 mois. Parmi ces patients, 83 ont été traités médicalement, 34 ont subi une fermeture du FOP par cathéter et 7 par chirurgie. Parmi les patients traités médicalement, 11 ont cessé de prendre la médication au cours du suivi. La récidive d'événements ischémiques et les facteurs de risque de récidive ont été analysés.

Résultats:

Le taux de récidive d'AVC était généralement faible et comparable chez les patients traités par cathéter et médicalement ainsi que chez ceux qui avaient cessé de prendre la médication (2,9% ; 2,1% ; 2,2% par année respectivement). Les patients qui ont présenté une récidive après fermeture du FOP par cathéter (n = 2) avaient tous deux un shunt résiduel. Aucune récidive n'a été observée chez les patients traités chirurgicalement. Un anévrisme du septum auriculaire ne prédisait pas la récidive ou les AVC multiples (p ˃ 0,05 ; rapport de cotes = 0,31 et = 0,74). Un shunt important et une histoire d'événements ischémiques antérieurs étaient beaucoup plus fréquents chez les patients qui présentaient des récidives d'AVC (p ˂ 0,05 ; rapport de cotes = 5,0 et = 4,4). Les taux d'embolie pulmonaire et de décès étaient significativement plus élevés chez les patients qui présentaient une récidive d'AVC (p ˂ 0,001 et p ˂ 0,01).

Conclusions:

Le risque absolu de récidive d'AVC chez les patients porteurs d'un FOP traités médicalement ou par cathéter est faible. Le petit groupe de patients non traités avait également un taux de récidive bas, comparable à celui de ces deux autres groupes de patients. Les événements ischémiques antérieurs et l'importance du shunt étaient des facteurs de risque dans cette étude d'observation. Étant donné les observations discordantes provenant de nombreuses études, une étude randomisée serait la meilleure option.

Type
Original Article
Information
Canadian Journal of Neurological Sciences , Volume 33 , Issue 1 , February 2006 , pp. 39 - 47
Copyright
Copyright © The Canadian Journal of Neurological 2006

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