Cryptogenic stroke and patent foramen ovale: Clinical clues to paradoxical embolism

Background: Patent foramen ovale (PFO) is an independent risk factor for cerebral infarction. Since similar to 25% of the population have a PFO, the simple association of PFO with stroke is not enough to establish the diagnosis of paradoxical embolism. We evaluated possible clinical Clues to the diagnosis of paradoxical embolism. Methods: Among patients with cryptogenic ischemic stroke (CS) who were investigated for a right-to-left shunt (RLS), we compared clinical, coagulation and biochemical parameters in patients with PFO versus without PFO. Results: Among 1689 new patients referred for TIA/non-disabling stroke between 2001 and 2007,175 with cryptogenic stroke (CS) were investigated for RLS by transcranial Doppler (TCD) bubble studies; 89 (5.5%) with positive TCD had a PFO confirmed by TEE. In multivariate logistic regression, a history of DVT or pulmonary embolism (OR, 4.39; 95% Cl, 1.23-15.69; p=0.023), prolonged travel (OR, 8.77; 95% Cl, 1.775-43.3; p=0.008), migraine (OR, 2.30: 95% Cl, 1.07-4.92: p=0.031), a Valsalva maneuver preceding the onset of focal neurological symptoms (OR, 3.33; 95% Cl, 1.15-9.64; p=0.026) and waking up with stroke/TIA (OR, 4.53, 95% Cl, 1.26-16.2; p=0.018) were independently associated with PFO-associated cerebrovascular events. Patients with PFO had higher plasma total homocysteine levels than patients without PFO (8.9 +/- 3 versus 7.9 +/- 2.6 mu mol/L respectively; p=0.021). Conclusions: A history of DVT or pulmonary embolism, migraine, recent prolonged travel, sleep apnea, waking up with TIA or stroke or a Valsalva maneuver preceding the event are clinical clues to the diagnosis of paradoxical embolism among patients with CS. (C) 2008 Elsevier B.V. All rights reserved.