High-risk patent foramen ovale and elderly in cryptogenic stroke

Kodai Kanemaru; Yuji Ueno; Muneaki Kikuno; Yohei Tateishi; Takahiro Shimizu; Ayako Kuriki; Ryosuke Doijiri; Hidehiro Takekawa; Yoshiaki Shimada; Eriko Yamaguchi; Masatoshi Koga; Yuki Kamiya; Masafumi Ihara; Akira Tsujino; Koichi Hirata; Yasuhiro Hasegawa; Hitoshi Aizawa; Nobutaka Hattori; Takao Urabe

doi:10.1016/j.jstrokecerebrovasdis.2023.107344

High-risk patent foramen ovale and elderly in cryptogenic stroke

J Stroke Cerebrovasc Dis. 2023 Nov;32(11):107344. doi: 10.1016/j.jstrokecerebrovasdis.2023.107344. Epub 2023 Sep 16.

Authors

Kodai Kanemaru¹, Yuji Ueno², Muneaki Kikuno¹, Yohei Tateishi³, Takahiro Shimizu⁴, Ayako Kuriki⁵, Ryosuke Doijiri⁶, Hidehiro Takekawa⁷, Yoshiaki Shimada⁸, Eriko Yamaguchi⁶, Masatoshi Koga⁹, Yuki Kamiya⁵, Masafumi Ihara¹⁰, Akira Tsujino³, Koichi Hirata⁷, Yasuhiro Hasegawa⁴, Hitoshi Aizawa¹¹, Nobutaka Hattori¹², Takao Urabe⁸

Affiliations

¹ Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology, Tokyo Medical University Hospital, Tokyo, Japan.
² Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan. Electronic address: yuji-u@juntendo.ac.jp.
³ Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan.
⁴ Department of Neurology, St. Marianna University School of Medicine, Kanagawa, Japan.
⁵ Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan.
⁶ Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan.
⁷ Department of Neurology, Dokkyo Medical University, Tochigi, Japan.
⁸ Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan.
⁹ Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.
¹⁰ Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan.
¹¹ Department of Neurology, Tokyo Medical University Hospital, Tokyo, Japan.
¹² Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan.

PMID: 37722223
DOI: 10.1016/j.jstrokecerebrovasdis.2023.107344

Abstract

Background: High-risk patent foramen ovale (PFO) could be pathological in cryptogenic stroke (CS), but its clinical characteristics have not been fully studied, especially in elderly patients.

Methods: Patients with CS were enrolled in the CHALLENGE ESUS/CS registry, a multicenter registry of CS patients undergoing transesophageal echocardiography. Clinical characteristics were compared among three groups: high-risk PFO group, large shunt PFO (≥25 microbubbles) or PFO with atrial septal aneurysm (ASA); right-to-left shunt (RLS) group, RLS including PFO with <25 microbubbles or without ASA; and no-RLS group.

Results: In total, 654 patients were analyzed: 91, 221, and 342 in the high-risk PFO, RLS, and no-RLS groups, respectively. In multinomial logistic regression analysis, the male sex (odds ratio [OR] 1.825 [1.067-3.122]) was independently associated with high-risk PFO, but hypertension (OR, 0.562 [0.327-0.967]), multiple infarctions (OR, 0.601 [0.435-0.830]), and other cardioaortic embologenic risks (OR, 0.514 [0.294-0.897]) were inversely associated with high-risk PFO compared with non-RLS. In 517 patients aged ≥60 years, multiple infarctions (OR, 0.549 [0.382-0.788]) and other cardioaortic embologenic risks (OR, 0.523 [0.286-0.959]) were inversely associated with high-risk PFO.

Conclusions: High-risk PFO had specific clinical characteristics and possible mechanistic associations, and this trend was consistent among CS patients aged ≥60 years.

Clinical trial registration information: http://www.umin.ac.jp/ctr/ (UMIN000032957).

Keywords: Cryptogenic stroke; Embolic stroke of undetermined source; Patent foramen ovale; Transesophageal echocardiography.