Ischemic Stroke with Patent Foramen Ovale

This section will summarize ischemic stroke with Patent foramen ovale (PFO) or atrial septal aneurysm

Diagnosis:

This Patent foramen ovale is associated with cryptogenic stroke, but is not the major cause of cryptogenic stroke. Consider this potential etiology in patients with non-lacunar stroke after investigations for intracranial atherosclerosis, extracranial atherosclerosis, atrial fibrillation (including long term cardiac monitoring), other causes of cardioembolism and other determined stroke etiologies such as dissection and vasculitis.

Diagnosis of Patent foramen ovale:

Tansoesophageal echocardiography with bubble study:

  • Right-to-left transit of contrast microbubbles within 3 to 4 cardiac cycles of right atrial opacification
  • May occur with or without atrial septal aneurysm

Trancranial doppler ultrasound (TCD) with bubble study is the most sensitive test for right to left shunt. This shunt may be due to PFO or other causes

Diagnosis Atrial septal aneurysm:

TTE, Transoesophageal echocardiography: >10-mm excursions of the interatrial septum with the cardiac cycle.

Treatment:

If associated with stroke:

  • Antiplatelet therapy: long term prognosis is excellent on aspirin ~2% stroke rate in NOMAS study
  • Anticoagulation if evidence of venous thrombosis
  • Consider closure if recurrent despite medical therapy and no other cause can be identified (including testing for paroxysmal atrial fibrillation)

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