Cryptogenic stroke and patent foramen ovale (abridged and translated version)
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(2019) 1:1
Neurological Research and Practice
GUIDELINES
Open Access
Cryptogenic stroke and patent foramen ovale (abridged and translated version) Hans-Christoph Diener1* , Armin Grau2* and Stephan Baldus3*
Abstract Interventional patent foramen ovale (PFO) closure should be performed in patients aged 16 to 60 years (after extensive neurological and cardiological diagnostic work-up) with a history of cryptogenic ischaemic stroke and patent foramen ovale, with moderate or extensive right-to-left shunt. In patients with cryptogenic ischaemic stroke and patent foramen ovale, who reject a PFO closure, there is no evidence of superiority of oral anticoagulation over antiplatelet therapy. Therefore, secondary prevention should be performed with aspirin or clopidogrel. Atrial fibrillation, pericardial tamponade, and pulmonary embolism are reported complications during and after implantation of an occluder. However, these events are so rare that they should not influence the recommendation for implantation. This article is an abridged and translated version of the guideline published in Nervenarzt: Diener, HC., für die Deutsche Gesellschaft für Neurologie (DGN), Grau, A.J. et al. Nervenarzt (2018) 89: 1143. https://doi.org/10.1007/s00115-018-0609-y. Keywords: Stroke, Ischemic stroke, Cryptogenic stroke, Echocardiography, Patent foramen ovale (PFO), Closure of patent foramen ovale, Antithrombotic therapy, Anticoagulation, Antiplatelet therapy
Need for a recommendation This article is an abridged and translated version of the guideline published in Nervenarzt: Diener, HC., für die Deutsche Gesellschaft für Neurologie (DGN), Grau, A.J. et al. Nervenarzt (2018) 89: 1143. https://doi.org/10.1007/ s00115-018-0609-y. In stroke patients under 60 years of age with a cryptogenic stroke, for which after extensive diagnostic work up no other potential cause other than a open foramen ovale is detected there are several options for secondary prevention of future strokes. These options include, antiplatelet therapy, anticoagulation and invasive occlusion of the patent foramen ovale (PFO). Previous guidelines gave only low level recommendations for any of these options. Recently, 4 randomized clinical trials on PFO-closure have been published, which changed the evidence base for treatment decisions. The previous DGN guidelines for the secondary prevention of cryptogenic stroke were published in 2012 * Correspondence: [email protected]; [email protected]; [email protected] 1 German Society of Neurology, Stuttgart, Germany 2 DSG German Stroke Society, Berlin, Germany 3 German Society of Cardiology, Düsseldorf, Germany
and did not reflect the more recent studies on the interventional closure of patent foramen ovale (PFO). In the meantime, the term cryptogenic stroke has been widely replaced by the criteria of embolic stroke of undetermined source (ESUS) which are applied to patients with cryptogenic stroke [1]. These include: 1. Evidence of cerebral ischaemia by CT or MRI and exclusion of lacunar infarcts 2. Exclusion of large
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