European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke

Patent foramen ovale: A variant of normal or a true congenital heart disease?

Foramen ovale plays a key role in foetal circulation, however it may remain patent after birth throughout the life. Its patency is so frequent in healthy people (27-35 %), such as to be considered a variant of normal. It is at risk of complications, like paradoxical embolism by right to left shunt with stroke, migraine, temporary blindness, as well as aneurysm, thrombosis and endocarditis of the fossa ovalis. There is no doubt that it should be considered a congenital heart disease at all effects. Invasive cardiology closure with umbrella and even with stiches is nowadays feasible and indicated in specific clinical scenarios. Further research is needed to determine whether cardiac echo-doppler screening for identifing affected patients as a primary prevention measure is advisable.

Managing anticoagulation and thromboembolic risk in cryptogenic stroke associated with patent foramen ovale

Cryptogenic stroke (CS) in young adults may be associated with the presence of a patent foramen ovale (PFO). This case report presents a woman in her 40s admitted with sudden left hemiplegia. Imaging confirmed an ischaemic stroke in the right middle cerebral artery territory and occlusion of the right internal carotid artery. Further investigations identified a large PFO associated with an atrial septal aneurysm. An in-depth assessment revealed a distal deep vein thrombosis (DVT). Initial anticoagulation therapy was interrupted due to severe metrorrhagia, necessitating the placement of an inferior vena cava (IVC) filter. Subsequent extensive thrombosis of the IVC led to initiation of low molecular weight heparin followed by long-term direct oral anticoagulants. This case highlights the complexity of managing CS with PFO, emphasising the importance of thorough aetiological evaluation to distinguish pathogenic from incidental PFO, and the need for a personalised and multidisciplinary therapeutic strategy to balance thromboembolic and haemorrhagic risks effectively.

Stroke recurrence after transcatheter PFO closure in patients with cryptogenic stroke

BACKGROUND

Patent foramen ovale (PFO) closure is recommended for secondary prevention of cryptogenic stroke. However, data on long-term results are limited. We aimed to evaluate safety and efficacy of transcatheter PFO closure and predict neurologic recurrence.

METHODS

Data from patients undergoing PFO closure between 2010 and 2015 were collected to assess the combined endpoint of transient ischemic attack (TIA), stroke, or death from stroke at short- and long-term follow-up.

RESULTS

330 patients were included, mean age was 49 (±12) years, and 55.5% were male. Before PFO closure, 86% experienced a stroke and 19% multiple neurological events. Procedure-related complications occurred in 2.4% of patients. Over a median follow-up of 10 years, the combined endpoint occurred in 3.6%, with a recurrence rate of 0.38 per 100 patient-years. Freedom from the combined endpoint at 5 and 10 years was 97.5% and 96.2%, respectively. New-onset atrial fibrillation was detected in 3%. The Risk of Paradoxical Embolism (RoPE) score (adjHR: 0.68; p = 0.032), the PFO-Associated Stroke Causal Likelihood (PASCAL) classification system (adjHR: 0.37; p = 0.042), and a history of prior neurological events (adjHR: 9.94; p < 0.001) were independent predictors of future recurrent neurologic events. Age, sex, and cardiovascular risk factors did not influence outcomes.

CONCLUSION

In this real-world cohort, transcatheter PFO closure was associated with low long-term recurrence of neurologic events, especially cryptogenic strokes. The RoPE score, the PASCAL score, and history of previous neurological events were predictive of recurrent events. This study supports the safety and efficacy of PFO closure for secondary prevention of cryptogenic strokes, and underscores the importance of patient selection.

Thalamic Infarctions: A Case Study of Inferolateral and Posterior Choroidal Branch Involvement in a Patient Without Classic Vascular Risk Factors

INTRODUCTION

Thalamic infarctions represent a rare subset of ischemic strokes, characterized by a diverse array of clinical manifestations and significant diagnostic challenges. These infarctions can lead to a wide range of neurological deficits, depending on the specific vascular territory involved. Infarctions within the posterior circulation territory of P2, particularly those affecting the inferolateral and posterior choroidal arteries, are associated with distinct neurological symptoms, including contralateral sensory loss, hemiparesis, hemiataxia, thalamic hand, and various sensory and motor disturbances.

CASE REPORT

We present the case of a 47-year-old woman with a unilateral thalamic infarction involving occlusion of the P2 branch of the posterior cerebral artery. The infarction, caused by a paradoxical embolism secondary to a high-grade patent foramen ovale (PFO) with an interatrial septal aneurysm, occurred in the absence of classic vascular risk factors. The patient exhibited a clinical syndrome consistent with ischemic lesions in the inferolateral and posterior choroidal arteries, manifesting as right-sided hemiparesthesia, hemiataxia with neuropathic pain, thalamic hand, dystonia, and tremor in the upper right limb.

CONCLUSION

Early and precise clinical identification of thalamic infarctions, especially in rare cases involving multiple vascular territories, is essential for improving patient care and outcomes. Recognizing the spectrum of potential symptoms facilitates effective symptom management, minimizes the risk of secondary complications, and optimize neurological rehabilitation.

Hotspots and frontiers in patent foramen ovale research: a bibliometric and visualization analysis from 2003 to 2023

Background

Patent foramen ovale (PFO) is among the most common congenital heart defects. Over the last two decades, the number of research publications on PFO has increased. This study aims to identify and describe the current state, hotspots, and emerging trends in PFO research over the previous 20 years using bibliometric analysis and visual mapping.

Methods

The Web of Science Core Collection was searched for all publications on PFO research, which were then included in the study. CtieSpace, VOSviewer, and Excel software were used to visualize general information, publication output, countries/regions, authors, journals, influential papers, and keyword trends in this field.

Results

This comprehensive analysis included 14,495 publications from 6,190 institutions across 115 countries. The United States dominated with the highest number of publications (2,407) and international collaborations. Mas JL made significant contributions to the PFO field, while Meier B emerged as a leading author, publishing 81 articles during the past 20 years. There were strong international collaborations among countries, institutions, and authors. Stroke, Circulation, and the New England Journal of Medicine were the most cited journals, with 13,124, 10,136, and 9,867 citations, respectively.

Conclusions

This bibliometric study revealed that recent research frontiers primarily focused on the diagnosis and clinical management of patients with PFO. Future studies are expected to delve deeper into the biological mechanisms by which PFO contributes to stroke, the efficacy and limitations of PFO closure techniques, and the exploration of genetic variations associated with PFO and their roles in disease susceptibility.

Enhancing the diagnostic efficacy of right-to-left shunt using robot-assisted transcranial Doppler: a quality improvement project

Background

Stroke is the leading cause of adult disability worldwide, with approximately 30% of strokes remaining cryptogenic. One potential important etiology is a patent foramen ovale (PFO), which may contribute to stroke through paradoxical thromboembolism or in situ thromboembolus formation. Recent advancements in robot-assisted transcranial Doppler (raTCD) have shown increased sensitivity in detecting right-to-left shunt (RLS) compared to transthoracic echocardiography (TTE), particularly in detecting the large shunts which are associated with higher stroke risk.

Methods

We conducted a retrospective quality improvement project at our regional stroke center to compare the performance of TTE and raTCD in identifying RLS in ischemic stroke patients. The study involved 148 patients admitted between February 2021 and February 2023. All patients underwent TTE and raTCD with agitated saline bubble contrast, with additional transesophageal echocardiography (TEE) at the treatment team's discretion. The primary metrics analyzed included differences in overall RLS detection and large RLS detection rates for raTCD, TTE and TEE.

Results

raTCD detected RLS in 60.1% of patients compared to 37.2% with TTE (p < 0.001), with a 42.6% detection rate for large shunts on raTCD versus 23.0% on TTE (p < 0.001). The sensitivity and specificity of raTCD were 92 and 87.5%, respectively, compared to 78.57 and 71.43% for TTE, using TEE as the gold standard. Nine patients underwent PFO closure, all correctly identified with large shunts by raTCD, while TTE missed or underestimated the PFO size in 44% of the cases.

Conclusion

raTCD significantly outperforms TTE in detecting RLS and large shunts, suggesting its integration into standard PFO workup protocols may enhance secondary stroke prevention. These findings support the adoption of raTCD as a complementary diagnostic tool alongside TTE and TEE for more accurate PFO detection and risk stratification.

In patients with ESUS, the effects of OAC and antiplatelet therapy on recurrent ischemic stroke differ across subgroups at 1 to 5 y

CLINICAL IMPACT RATINGS

GIM/FP/GP: [Formula: see text] Neurology: [Formula: see text].

Risk factors, mechanisms, and clinical outcomes of stroke in young adults presenting to a North Central London stroke service: UCL Young Stroke Systematic Evaluation Study (ULYSSES)

INTRODUCTION

Stroke incidence in younger adults is increasing worldwide yet few comprehensive studies exist from a UK population. We investigated the risk factors, mechanisms, functional outcome and stroke recurrence rate in a cohort of young adults with stroke.

PATIENTS AND METHODS

We included consecutive patients (<55 years) with ischaemic stroke or intracerebral haemorrhage (ICH) admitted to the University College London Hospitals Hyperacute Stroke Unit between 2017 and 2020. Ischaemic stroke was classified using Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria and ICH using modified CLAS-ICH criteria. Multivariable logistic regression was performed to identify predictors of unfavourable functional outcome (modified Rankin Scale [mRS] > 1) at 6 months.

RESULTS

Five hundred fifty-two patients were included (median age 47, IQR 41-51; 33% female; 76% ischaemic stroke). Common risk factors included dyslipidaemia (57%), hypertension (40%), and cigarette smoking (34%). Ischaemic stroke was mostly due to cardioembolism (22%). Probable cerebral small vessel disease was the most frequent ICH aetiology (53%). Unfavourable functional outcome was prevalent in 50% at 6 months and was associated with ICH (OR 2.02, 95%CI 1.14-3.58, p = 0.017), female sex (OR 1.62, 95%CI 1.03-2.55, p = 0.037), admission stroke severity (per point increase, OR 1.11, 95%CI 1.07-1.16, p < 0.001) and pre-morbid mRS 2-5 (OR 3.16; 95%CI 1.11-9.03, p = 0.032). 4.4% had a recurrent stroke within 6 months.

DISCUSSION AND CONCLUSION

Traditional cardiovascular risk factors are common in young adults with stroke. Unfavourable functional outcome is associated with female sex, ICH, severe stroke and pre-morbid disability. These findings can inform national stroke prevention and rehabilitation strategies.

Association of Slender Patent Ductus Arteriosus Combined With PFO Related to the Transient Ischemic Attack: A Rare Case Report

It was a rare case of a 52-year-old female with a slender PDA combined with PFO related to a transient ischemic attack that did not improve with aspirin and/or clopidogrel treatment. We closed the PDA using the ADO-II occluder and closed the PFO with the occluder, resulting in symptom resolution.

Patent Foramen Ovale Occlusion in Elderly Patients: Is It Worth It? A Large, Single-Center Retrospective Analysis

Background: Patent foramen ovale (PFO) is often diagnosed in patients with cryptogenic stroke, aged > 60-65 years, but few data report the outcomes of PFO closure in elderly patients. Methods: Consecutive patients undergoing PFO closure at a single institution between January 2006 and December 2011 were included. Baseline clinical features and cerebral imaging data were collected, and a RoPE score was calculated for each patient. Procedural data were recorded as well as medical therapy upon discharge. All-cause death, ischemic stroke, TIA and systemic embolism recurrence at long-term follow-up were investigated, as well as new atrial fibrillation onset. Results: Overall, 462 patients were included, of whom 64 (13.8%) were aged ≥ 65 years. Female gender was slightly more prevalent in the younger group while hypertension was more frequent among elderly patients. Previous stroke/TIA was the indication for PFO closure in 95.3% of older patients and 80.4% of younger patients, whereas other indications were more frequent among younger patients. RoPE scores were lower in older patients (median RoPE score of 5 vs. 7), and atrial septal aneurysm was more frequently detected among elderly patients. All procedures were technically successful. Procedural or in-hospital complications equally occurred in 5 (7.8%) older patients (4 AF and 1 device embolization) and 30 (7.5%) young patients (29 AF or other supraventricular arrhythmias and 1 device embolization). The follow-up duration was longer among younger patients. All-cause mortality was higher in older patients (16 deaths vs. 4 at follow-up, log-rank p < 0.001), no recurrent strokes occurred, and 2 TIAs were reported among non-elderly patients. New-onset atrial fibrillation occurred in three elderly and eight young patients. Conclusions: PFO closure is a safe procedure in patients aged ≥ 65 years, associated with favorable long-term follow-up and the prevention of ischemic neurologic recurrences.