White matter lesions as a prognostic marker of recurrence in cryptogenic stroke with high-risk patent foramen ovale

Abstract

AbstractIntroductionAtrial septal aneurysms increase the risk of stroke recurrence in cryptogenic stroke patients with a patent foramen ovale. Factors related to stroke recurrence according to the patent foramen ovale risk stratification have not been fully evaluated.MethodsData from a multicenter observational registry of ischemic stroke patients undergoing transesophageal echocardiography, with a comprehensive database including clinical characteristics and long-term prognosis, were used for this study. Patients were classified into three groups: high-risk patent foramen ovale group, large shunt patent foramen ovale (≥20 microbubbles) or patent foramen ovale with atrial septal aneurysm; right-to-left shunt group, right-to-left shunt including patent foramen ovale with <20 microbubbles or without atrial septal aneurysm; and negative right-to-left shunt group. Among stroke subtype, factors related to stroke recurrence were investigated according to the risk stratification of patent foramen ovale in cryptogenic stroke.ResultsIn total, 586 patients (185 females; 65.5 ± 13.2 years) were analyzed. In cryptogenic stroke (329 patients) with median follow-up of 4.2 (interquartile range, 1.0– 6.1) years, 55 patients had stroke recurrence. The negative right-to-left shunt, right-to-left shunt, and high-risk patent foramen ovale groups included 179, 90, and 60 patients, in which stroke recurrence occurred in 5.3%, 2.5%, and 4.6% per person-year, respectively. In patients with high-risk patent foramen ovale, the NIH stroke scale score (hazard ratio 1.257, 95% CI 1.034-1.530,P=0.022) and periventricular hyperintensity (hazard ratio 3.369, 95% CI 1.103-10.294,P=0.035) were predictive markers for stroke recurrence on multivariate Cox Hazards analysis, but no factors were related to stroke recurrence in the right-to-left shunt and negative right-to-left shunt groups.ConclusionHigh-risk patent foramen ovale is an important embolic source in cryptogenic stroke. Periventricular hyperintensity was shown to predict recurrent stroke in patients with a high-risk patent foramen ovale. In such cases, percutaneous patent foramen ovale closure might be effective at <60 years of age.