title: Patent foramen ovale may be causal for the first stroke but unrelated to subsequent ischemic events.
abstract: OBJECTIVE
  Studies with very long follow-up are scarce in patients with cryptogenic stroke and patent foramen ovale (PFO). Little is known about the etiology of recurrent cerebrovascular events (CVE) in PFO patients.
  
  
  METHODS
  We collected information on recurrent CVE in 308 patients with cryptogenic stroke and PFO and sought to determine concurrent stroke causes that had emerged or been newly detected since the index event. One hundred fifty-eight patients received aspirin (48%), clopidogrel (2%), or oral anticoagulants (50%; medical group). One hundred fifty patients underwent percutaneous PFO closure (closure group).
  
  
  RESULTS
  Mean age at index event was 50 years (SD 13). In 33% of patients, the index stroke or transient ischemic attack was preceded by at least 1 CVE. Mean follow-up was 8.7±4.0 years. During follow-up, 32 recurrent CVE (13 strokes and 19 transient ischemic attacks) occurred in the medical and 16 recurrent CVE (8 strokes and 8 transient ischemic attacks) in the closure group. Concurrent etiologies were identified for 12 recurrent CVE in the medical group (38%): large artery disease (9%), small artery disease (6%), cardioembolism (13%), cerebral vasculitis (3%), and antiphospholipid-antibody-syndrome (6%). In the closure group, 7 recurrent CVE had a concurrent etiology (44%): large artery disease (6%), small artery disease (19%), cardioembolism (13%), and thrombophilic disorder (6%). The frequency of concurrent etiologies did not differ between patients with recurrent CVE under medical treatment and those undergoing PFO closure (P=0.68).
  
  
  CONCLUSIONS
  Concurrent etiologies are identified for more than one third of recurrent ischemic events in patients with cryptogenic stroke, casting doubt on the sole causal role of PFO.
authors.affiliation: Department of Neurology, Inselspital, University Hospital and University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.
authors.forename: Marie-Luise
authors.initials: ML
authors.lastname: Mono
authors.forename: Laura
authors.initials: L
authors.lastname: Geister
authors.forename: Aekaterini
authors.initials: A
authors.lastname: Galimanis
authors.forename: Simon
authors.initials: S
authors.lastname: Jung
authors.forename: Fabien
authors.initials: F
authors.lastname: Praz
authors.forename: Marcel
authors.initials: M
authors.lastname: Arnold
authors.forename: Urs
authors.initials: U
authors.lastname: Fischer
authors.forename: Stefan
authors.initials: S
authors.lastname: Wolff
authors.forename: Oliver
authors.initials: O
authors.lastname: Findling
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.forename: Andreas
authors.initials: A
authors.lastname: Wahl
authors.forename: Bernhard
authors.initials: B
authors.lastname: Meier
authors.forename: Heinrich P
authors.initials: HP
authors.lastname: Mattle
authors.forename: Krassen
authors.initials: K
authors.lastname: Nedeltchev
mesh_terms: D000328:Adult; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D002545:Brain Ischemia / Q000188:drug therapy / Q000209:etiology*; D000077144:Clopidogrel; D005260:Female; D005500:Follow-Up Studies; D054092:Foramen Ovale, Patent / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012008:Recurrence; D020521:Stroke / Q000188:drug therapy / Q000209:etiology*; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin