Patent foramen ovale closure reduces recurrent stroke risk in cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials

Diagnostic Value of Micro-Bubble Transcranial Doppler Combined with Contrast Transthoracic Echocardiography in Cryptogenic Stroke Patients with Patent Foramen Ovale

Background

In recent years, increasing attention has been paid to cryptogenic stroke (CS) caused by the patent foramen ovale (PFO).

Objective

This study aims to evaluate the value of microbubble transcranial Doppler (MB-TCD) combined with contrast transthoracic echocardiography (cTTE) in the diagnosis of cryptogenic stroke patients with PFO.

Materials and Method

From January 2014 to January 2019, patients who suffered from CS were recruited and divided into the cTTE group and MB-TCD combined with cTTE group. All patients were further checked by transesophageal echocardiography (TEE).

Results

A total of 130 patients accepted cTTE examination, and 109 patients accepted MB-TCD combined with cTTE. In the group, 52 of the 54 positive patients were finally confirmed by TEE with PFO, and 12 of the 76 negative patients were finally confirmed by TEE with PFO. In combined group, 50 patients were negative on both two examination (Negative group), 54 were positive on both two examination (Positive group) and finally confirmed by TEE indeed with patent foramen ovale (PFO), while remaining five (5) patients were positive only on MB-TCD (Suspected group). After checked by TEE, three (3) of five patients with MB-TCD positive were confirmed by TEE indeed with PFO. The sensitivity, specificity, positive likelihood ratio (+LR), and Youden's index of cTEE in diagnostic of cryptogenic stroke patients with PFO were 81.25%, 96.97%, 26.82 and 0.78, respectively, and these for MB-TCD combined with cTTE were 100%, 96.15%, 25.97 and 0.96, respectively. MB-TCD medium can sensitively discover PFO in cryptogenic stroke patients with 100% sensitivity and a missdiagnosis rate of 0.

Conclusion

The combination of MB-TCD and cTTE can improve the sensitivity and specificity of PFO diagnosis in cryptogenic stroke patients. MB-TCD medium also had high sensitivity and specificity.

Role of PFO Closure in Ischemic Stroke Prevention

PURPOSE OF REVIEW

To highlight recent advancements in the management of acute ischemic stroke patients with patent foramen ovale (PFO).

RECENT FINDINGS

One significant recent development was publication of long-term follow-up data from the RESPECT trial demonstrating evidence in favor of PFO closure over medical management. This data subsequently led to FDA approval for AMPLATZER™ septal occluder in the treatment of patients aged 18 to 60 years with both PFO and no other determined etiology for ischemic stroke, otherwise referred to as embolic stroke of undetermined source. Several subsequent closure trial results have recently been published, which also demonstrated benefit of PFO closure over medical management for ischemic stroke risk reduction in select patients. Based on the results of the more recently published REDUCE trial, the FDA granted approval for the GORE™ septal occluder. There is current, well-established evidence that PFO closure for secondary stroke prevention is effective in select cases.

Atrial septal aneurysm with rare comorbid pulmonary arteriovenous malformation as aetiology for cryptogenic stroke

Atrial septal aneurysms have two mechanisms for cardioembolic events. One is the aneurysm itself can act as a nidus for thrombus formation in the left atrium. The aneurysm creates an area of low turbulence leading to haemostasis allowing fibrin-platelet adhesions to form. If the clot is on the left atrial wall, it may be dislodged by oscillations of the septum and travel into the systemic circulation. The second mechanism is via, an often comorbid, interatrial shunt such as a Patent Foramen Ovale or Atrial Septal Defect. We report a unique case where the associated right to left shunt leading to the cryptogenic stroke is a pulmonary arteriovenous malformation.