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Recurrent Stroke/TIA in Cryptogenic Stroke Patients with Patent Foramen Ovale

Published online by Cambridge University Press:  02 December 2014

Leanne Casaubon ,
Peter McLaughlin ,
Gary Webb ,
Erik Yeo ,
Darren Merker  and
Cheryl Jaigobin
Leanne Casaubon
Affiliation:
University Health Network, Toronto General Hospital, Toronto, ON, Canada
Peter McLaughlin
Affiliation:
University Health Network, Toronto General Hospital, Toronto, ON, Canada
Gary Webb
Affiliation:
University Health Network, Toronto General Hospital, Toronto, ON, Canada
Erik Yeo
Affiliation:
University Health Network, Toronto General Hospital, Toronto, ON, Canada
Darren Merker
Affiliation:
University Health Network, Toronto General Hospital, Toronto, ON, Canada
Cheryl Jaigobin
Affiliation:
University Health Network, Toronto General Hospital, Toronto, ON, Canada
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Abstract

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Background:

Patent foramen ovale (PFO) is present in 40% of patients with cryptogenic stroke and may be associated with paradoxical emboli to the brain. Therapeutic options include antiplatelet agents, anticoagulation, percutaneous device and surgical closure. We assessed the hypothesis that there are differences in rates of recurrent TIA or stroke between patients in the four treatment groups.

Methods:

Patients presenting from January 1997 with cryptogenic stroke or TIA and PFO were followed prospectively until June 2003. Treatment choice was made on an individual case basis. The primary outcome was recurrent stroke. The secondary outcome was a composite of stroke, TIA, and vascular death.

Results:

Baseline. Our cohort consisted of 121 patients; 64 (53%) were men. Median age was 43 years. Sixty-nine percent presented with stroke and 31% with TIA. One or more vascular risk factor was present in 40%. Atrial septal aneurysm (ASA) was present in 24%. Treatment consisted of antiplatelet agents (34%), anticoagulation (17%), device (39%) and surgical closure (11%). Follow-up. Recurrent events occurred in 16 patients (9 antiplatelet, 3 anticoagulation, 4 device closure); 7 were strokes, 9 were TIA. Comparing individual treatments there was a trend toward more strokes in the antiplatelet arm (p=0.072); a significant difference was seen for the composite endpoint (p=0.012). Comparing closure versus combined medical therapy groups, a significant difference was seen for primary (p=0.014) and secondary (p=0.008) outcomes, favoring closure. Age and pre-study event predicted outcome.

Conclusion:

Patent foramen ovale closure was associated with fewer recurrent events. Complications of surgical and device closure were self-limited.

Résumé:

RÉSUMÉ:Contexte:

Parmi les patients qui présentent un accident vasculaire cérébral (AVC) cryptogénique, 40% sont porteurs d'un foramen ovale perméable (FOP) qui peut être à l'origine d'une embolie paradoxale au cerveau. Les différentes options thérapeutiques sont : les antiplaquettaires, les anticoagulants, un dispositif percutané et la fermeture chirurgicale. Notre hypothèse était que le taux de récidive de l'accident ischémique transitoire (AIT) ou de l'AVC est différent selon que le patient reçoit l'un ou l'autre de ces traitements.

Méthodes:

Il s'agit d'une étude prospective de tous les patients porteurs d'un FOP ayant subi un AVC ou un AIT cryptogénique depuis janvier 1997 et qui ont été suivis jusqu'en juin 2003. Le choix du traitement était individualisé. Le critère d'évaluation principal était la récidive d'AVC. Le critère d'évaluation secondaire était composé de l'AVC, de l'AIT et du décès d'origine vasculaire.

Résultats:

Notre cohorte était constituée de 121 patients dont 64 étaient des hommes (53%). L'âge médian était de 43 ans. Soixante-neuf pour cent ont consulté pour un AVC et 31% pour un AIT. Quarante pour cent avaient un ou plusieurs facteurs de risque vasculaires et 24% avaient un anévrisme septal auriculaire. Trente-quatre pour cent ont reçu des antiplaquettaires, 17% ont été anticoagulés, 39% ont reçu un dispositif percutané et 11% ont subi une occlusion chirurgicale. Au cours du suivi, 16 patients ont subi une récidive, soit un AVC chez 7 et un AIT chez 9. Neuf de ces patients étaient sous antiplaquettaires, 3 patients étaient anticoagulés et 4 patients avaient reçu un dispositif percutané. En comparant les quatre traitements, on note une tendance à observer plus d'AVC sous traitement antiplaquettaire (p = 0,072); la différence était significative pour le critère d'évaluation composé (p = 0,012). La différence entre la fermeture et les traitements médicaux était significative tant en ce qui concerne le critère d'évaluation principal (p = 0,014) que le critère d'évaluation secondaire (p = 0,008), en faveur de la fermeture. L'âge et l'événement précédant l'étude prédisait l'issue.

Conclusion:

Moins de récidives ont été observées chez les patients qui ont subi une occlusion du FOP. Les complications de la chirurgie et de l'implantation d'un dispositif percutané étaient autolimitées.

Type
Original Articles
Information
Canadian Journal of Neurological Sciences , Volume 34 , Issue 1 , February 2007 , pp. 74 - 80
Copyright
Copyright © The Canadian Journal of Neurological 2007

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