Patent foramen ovale as the cause of recurrent embolic strokes. Case report

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Abstract

А clinical case of a young patient with recurrent ischemic strokes is presented. The problems of diagnostic embolic strokes are discussed. We set out the algorithm for identifying patients, in whom patent foramen ovale is the most probable cause of embolic stroke. Detailed consideration of imaging diagnostic methods possibility is included. Hypothesis of probable source of cardioembolism from patent foramen ovale is presented. Recommendations for the secondary prevention of recurrent ischemic stroke, associated with patent foramen ovale, are provided. We also considered the issues of antithrombotic treatment.

About the authors

Andrey L. Komarov

Chazov National Medical Research Center of Cardiology

Email: lena-4ka@yandex.ru
ORCID iD: 0000-0001-9141-103X

д-р мед. наук, вед. науч. сотр. отд. клинических проблем атеротромбоза

Russian Federation, Moscow

Elena N. Krivosheeva

Chazov National Medical Research Center of Cardiology

Author for correspondence.
Email: lena-4ka@yandex.ru
ORCID iD: 0000-0003-1146-9974

канд. мед. наук, мл. науч. сотр. отд. клинических проблем атеротромбоза

Russian Federation, Moscow

Maksim I. Makeev

Chazov National Medical Research Center of Cardiology

Email: lena-4ka@yandex.ru
ORCID iD: 0000-0002-4779-5088

врач ультразвуковой диагностики

Russian Federation, Moscow

Evgeny V. Merkulov

Chazov National Medical Research Center of Cardiology

Email: lena-4ka@yandex.ru
ORCID iD: 0000-0001-8193-8575

д-р мед. наук, ст. науч. сотр., зав. отд-нием рентгенэндоваскулярных методов диагностики и лечения

Russian Federation, Moscow

Maria I. Tripoten

Chazov National Medical Research Center of Cardiology

Email: lena-4ka@yandex.ru
ORCID iD: 0000-0003-4462-3894

канд. мед. наук, науч. сотр., врач ультразвуковой диагностики отд-ния ультразвуковой диагностики

Russian Federation, Moscow

Elizaveta P. Panchenko

Chazov National Medical Research Center of Cardiology

Email: lena-4ka@yandex.ru
ORCID iD: 0000-0002-1174-2574

д-р мед. наук., проф., рук-ль отд. клинических проблем атеротромбоза

Russian Federation, Moscow

References

  1. Béjot Y, Bailly H, Durier J, Giroud M. Epidemiology of stroke in Europe and trends for the 21st century. La Presse Médicale. 2016;45(12):e391-8. doi: 10.1016/j.lpm.2016.10.003
  2. Virani S, Alonso A, Benjamin E, et al. Heart Disease and Stroke Statistics – 2020 Update: A Report From the American Heart Association. Circulation. 2020;141(9):e139-596. doi: 10.1161/cir.0000000000000757
  3. Акжигитов Р.Г., Алекян Б.Г., Алферова В.В., и др. Клинические рекомендации. Ишемический инсульт и транзиторная ишемичес- кая атака у взрослых. М.: Атомиздат, 2021. Режим доступа: https://www.neurology.ru/klinicheskie-rekomendacii-ishemicheskiy-insult-i-tranzitornaya-ishemicheskaya-ataka-u-vzroslyh. Ссылка активна на 11.09.2022 [Akzhigitov RG, Alekian BG, Alferova VV, et al. Klinicheskie rekomendatsii. Ishemicheskii insul't i tranzitornaia ishemicheskaia ataka u vzroslykh. Moscow: Atomizdat, 2021. Available at: https://www.neurology.ru/klinicheskie-rekomendacii-ishemicheskiy-insult-i-tranzitornaya-ishemicheskaya-ataka-u-vzroslyh. Accessed: 11.09.2022 (in Russian)].
  4. Adams H, Bendixen B, Kappelle L, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41. doi: 10.1161/01.str.24.1.35
  5. Kleindorfer D, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467. doi: 10.1161/str.0000000000000375
  6. Hart R, Diener H, Coutts S, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurology. 2014;13(4):429-38. doi: 10.1016/s1474-4422(13)70310-7
  7. Ntaios G, Perlepe K, Lambrou D, et al. Prevalence and Overlap of Potential Embolic Sources in Patients With Embolic Stroke of Undetermined Source. J Am Heart Assoc. 2019;8(15):e012858. doi: 10.1161/jaha.119.012858
  8. Ahmed N, Audebert H, Turc G, et al. Consensus statements and recommendations from the ESO-Karolinska Stroke Update Conference, Stockholm 11–13 November 2018. Eur Stroke J. 2019;4(4):307-17. doi: 10.1177/2396987319863606
  9. Hart R, Catanese L, Perera K, et al. Embolic Stroke of Undetermined Source. Stroke. 2017;48(4):867-72. doi: 10.1161/strokeaha.116.016414
  10. Hart R, Sharma M, Mundl H, et al. Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source. N Engl J Med. 2018;378(23):2191-201. doi: 10.1056/nejmoa1802686
  11. Ntaios G, Papavasileiou V, Milionis H, et al. Embolic Strokes of Undetermined Source in the Athens Stroke Registry. Stroke. 2015;46(8):2087-93. doi: 10.1161/strokeaha.115.009334
  12. Diener H, Sacco R, Easton J, et al. Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source. N Engl J Med. 2019;380(20):1906-17. doi: 10.1056/nejmoa1813959
  13. Toyoda K, Uchiyama S, Hagihara Y, et al. Dabigatran vs. Aspirin for Secondary Prevention After Embolic Stroke of Undetermined Source – Japanese Subanalysis of the RE-SPECT ESUS Randomized Controlled Trial. Circ J. 2020;84(12):2286-95. doi: 10.1253/circj.CJ-20-0563
  14. Healey J, Gladstone D, Swaminathan B, et al. Recurrent Stroke With Rivaroxaban Compared With Aspirin According to Predictors of Atrial Fibrillation. JAMA Neurol. 2019;76(7):764-73. doi: 10.1001/jamaneurol.2019.0617
  15. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020;42(5):373-498. doi: 10.1093/eurheartj/ehaa612
  16. Schnabel R, Haeusler K, Healey J, et al. Searching for Atrial Fibrillation Poststroke. Circulation. 2019;140(22):1834-50. doi: 10.1161/circulationaha.119.040267
  17. Kasner S, Swaminathan B, Lavados P, et al. Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial. Lancet Neurol. 2018;17(12):1053-60. doi: 10.1016/s1474-4422(18)30319-3
  18. Mojadidi M, Winoker J, Roberts S, et al. Accuracy of Conventional Transthoracic Echocardiography for the Diagnosis of Intracardiac Right-to-Left Shunt: A Meta-Analysis of Prospective Studies. Echocardiography. 2014;31(9):1036-48. doi: 10.1111/echo.12583
  19. Schnabel R, Camen S, Knebel F, et al. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol. 2021;110(7):938-58. doi: 10.1007/s00392-021-01834-x
  20. Pristipino C, Sievert H, D'Ascenzo F, et al. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eurointervention. 2019;14(13):1389-402. doi: 10.4244/eij-d-18-00622
  21. Giblett J, Williams L, Kyranis S, et al. Patent Foramen Ovale Closure: State of the Art. Interventional. Interv Cardiol. 2020;15:e15. doi: 10.15420/icr.2019.27
  22. Kent D, Ruthazer R, Weimar C, et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology. 2013;81(7):619-25. doi: 10.1212/wnl.0b013e3182a08d59
  23. Kent D, Saver J, Ruthazer R, et al. Risk of Paradoxical Embolism (RoPE) – Estimated Attributable Fraction Correlates With the Benefit of Patent Foramen Ovale Closure. Stroke. 2020;51(10):3119-23. doi: 10.1161/strokeaha.120.029350
  24. Mojadidi M, Bogush N, Caceres J, et al. Diagnostic Accuracy of Transesophageal Echocardiogram for the Detection of Patent Foramen Ovale: A Meta-Analysis. Echocardiography. 2013;31(6):752-8. doi: 10.1111/echo.12462
  25. Mojadidi M, Roberts S, Winoker J, et al. Accuracy of Transcranial Doppler for the Diagnosis of Intracardiac Right-to-Left Shunt. JACC Cardiovascular Imaging. 2014;7(3):236-50. doi: 10.1016/j.jcmg.2013.12.011
  26. Yan C, Li H. Preliminary Investigation of In situ Thrombus Within Patent Foramen Ovale in Patients With and Without Stroke. JAMA. 2021;325(20):2116. doi: 10.1001/jama.2021.4359
  27. Hakeem A, Cilingiroglu M, Katramados A, et al. Transcatheter closure of patent foramen ovale for secondary prevention of ischemic stroke: Quantitative synthesis of pooled randomized trial data. Catheter Cardiovasc Interv. 2018;92(6):1153-60. doi: 10.1002/ccd.27487
  28. Turc G, Calvet D, Guérin P, et al. Closure, Anticoagulation, or Antiplatelet Therapy for Cryptogenic Stroke With Patent Foramen Ovale: Systematic Review of Randomized Trials, Sequential Meta-Analysis, and New Insights From the CLOSE Study. J Am Heart Assoc. 2018;7(12):e008356. doi: 10.1161/jaha.117.008356

Supplementary files

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2. Fig. 1. Schematic representation of the medical history of patient A.

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3. Fig. 2. Magnetic resonance imaging of the brain 6 months after the development of ischemic stroke. Cortical-subcortical infarction in the basin of the left middle cerebral artery (T2 mode: hyperintense signal in the basin of the left middle cerebral artery).

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4. Fig. 3. Transcranial dopplerography with "bubble" test during the Valsalva maneuver.

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5. Fig. 4. Transesophageal echocardiography (a) with a "bubble" test (b) during the Valsalva maneuver. Passage of over 30 air bubbles through the foramen ovale.

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