title: Spontaneous large right-to-left shunt and migraine headache with aura are risk factors for recurrent stroke in patients with a patent foramen ovale.
abstract: BACKGROUND
  We sought to determine whether migraine headache with aura (MHA) and spontaneous large right-to-left (R-L) shunt are risk factors for recurrent cerebral ischemic events in cryptogenic stroke patients with a patent foramen ovale (PFO).
  
  
  METHODS
  140 patients with a PFO and cryptogenic stroke underwent transcatheter defect closure at our institution at a mean age of 45+/-13 years. We retrospectively analyzed follow-up data from the first cerebral ischemic event to the time of PFO closure. Before the procedure, all patients underwent transesophageal echocardiography (TEE); Transcranial Doppler scanning (TCD) was additionally performed on the last 59 patients. We analyzed the impact of MHA, thrombophilia, spontaneous large R-L shunt, and atrial septal aneurysm (ASA) on the risk of recurrent cerebral ischemic events.
  
  
  RESULTS
  44 patients (31%) had had at least 1 recurrent event during a follow-up of 2.2+/-2.6 years. Patients with recurrent events were more commonly females (p=0.0001), had more often an associated thrombophilia (p=0.0077), and had a higher prevalence of spontaneously large R-L shunt both at TEE and at TCD (p<0.05). They also had more commonly a history of MHA (p=0.0009) and more frequent episodes of MHA (p=0.0048). Patients with MHA had a higher risk of recurrent events when compared to patients without (odds ratio 3.87, 95% CI 1.75 to 8.50). Thrombophilia (p=0.001) and spontaneous large R-L shunt (p=0.02) were independent predictors of recurrent stroke.
  
  
  CONCLUSIONS
  In cryptogenic stroke patients with a PFO, a history of MHA, large spontaneous large R-L shunt, and thrombophilia are all associated with a higher risk of recurrent events.
authors.affiliation: Pediatric Cardiology and Adult Congenital Unit, University of Bologna, Italy. alessandro5574@iol.it
authors.forename: Alessandro
authors.initials: A
authors.lastname: Giardini
authors.forename: Andrea
authors.initials: A
authors.lastname: Donti
authors.forename: Roberto
authors.initials: R
authors.lastname: Formigari
authors.forename: Luisa
authors.initials: L
authors.lastname: Salomone
authors.forename: Gualtiero
authors.initials: G
authors.lastname: Palareti
authors.forename: Donata
authors.initials: D
authors.lastname: Guidetti
authors.forename: Fernando Maria
authors.initials: FM
authors.lastname: Picchio
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006344:Heart Septal Defects, Atrial / Q000150:complications* / Q000601:surgery; D006801:Humans; D002546:Ischemic Attack, Transient / Q000150:complications*; D008297:Male; D008875:Middle Aged; D020325:Migraine with Aura / Q000150:complications*; D015999:Multivariate Analysis; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D020521:Stroke / Q000150:complications*; D019851:Thrombophilia / Q000150:complications