PFO/Stroke in the Young

This morning we discussed a case of stroke in the young. See a previous blog post on stroke in the young here.

Two specific points with respect to this came up:

1) In patients with cryptogenic stroke, does PFO closure prevent recurrent strokes?

Answer: in a recent (NEJM 2012) unblinded multicenter study of 909 patients (ages 18-60yrs) randomised to closure or medical management (antiplatelet or anticoagulation at physician's discretion), there was no significant difference in the primary endpoint (composite of stroke or TIA in 2 years, death of any cause in 30 days, and death from neurological cause at 31 days to 2 years). See the study here.


2) One question that this brings up for me: does anticoagulation prevent recurrent strokes in patients with PFOs?

Answer: data and expert opinion are conflicted as to the optimal medical management of a patent foramen ovale in a patient with an otherwise cryptogenic stroke. In this study subgroup, patients were randomised to ASA 325mg or warfarin following stroke (250 cryptogenic out of a total 601 strokes). Of note, PFO was found in 39.2% (98/250) of patients with cryptogenic stroke, compared with 29.9% (105/351) in patients with known cause of stroke. Note that this is not a huge difference in prevalence between the two groups.

With respect to treatment, there was no significant difference in the time to recurrent ischemic stroke or death between those treated with warfarin and those treated with aspirin (P=0.49; hazard ratio 1.29; 95% CI 0.63 to 2.64; 2-year event rates 16.5% versus 13.2%).

There is some data suggesting that the presence of an atrial septal aneurysm along with a PFO confers greater risk.

The AHA Guidelines from 2011 are as follows:

- For patients with an ischemic stroke or TIA and a PFO, antiplatelet therapy is reasonable (Class IIa; Level of Evidence B). 

- There are insufficient data to establish whether anticoagulation is equivalent or superior to aspirin for secondary stroke prevention in patients with PFO (Class IIb; Level of Evidence B). (New recommendation)

 
- There are insufficient data to make a recommendation regarding PFO closure in patients with stroke and PFO (Class IIb; Level of Evidence C)

3) Finally: What the heck is CADASIL?

Answer from Harrison's:  
-  cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
- inherited disorder that presents as small-vessel strokes, progressive dementia, and extensive symmetric white matter changes visualized by MRI.  
- 40% of these patients have a history of migraine with aura. 


See you tomorrow!