Soon Tjin Lim1, Stephen J X Murphy1, Deirdre R Smith2, Jennifer Williams3, Silvia Gil Navarro3, John McCabe3, David P Moore4, Johnny McHugh5, Dominick J H McCabe6. 1. Department of Neurology, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland; Stroke Service, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland. 2. Vascular Neurology Research Foundation, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland. 3. Department of Neurology, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland. 4. Department of Cardiology, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland. 5. Department of Haematology, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland. 6. Department of Neurology, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland; Stroke Service, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland; Vascular Neurology Research Foundation, The Adelaide and Meath Hospital, incorporating The National Children's Hospital, Dublin, Ireland; Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College, Dublin, Ireland. Electronic address: dominick.mccabe@amnch.ie.
Abstract
INTRODUCTION: Data are limited on the optimal management of cryptogenic TIA/stroke patients with a patent foramen ovale (PFO)±inter-atrial septal aneurysm (IASA), especially with an inherited thrombophilia. METHODS: Prospectively-collected data on TIA/ischaemic stroke patients with PFO, IASA or both who received 'goal-directed secondary-prevention medical treatment' were analysed. All patients had trans-oesophageal echocardiography, anti-nuclear, anti-cardiolipin, anti-beta 2 glycoprotein I antibodies, rheumatoid factor, lupus anticoagulant, protein C&S, anti-thrombin, factor VIII activity, activated protein C resistance, Factor V Leiden, prothrombin gene and MTHFR-c.677C>T mutation screening. ENA and homocysteine were assessed in the latter study period. RESULTS: Eighty-three patients were recruited. Mean follow-up: 48.1months. Forty-seven patients (56.6%) had an isolated PFO, 32 (38.6%) a PFO and an IASA, and 4 (4.8%) an IASA alone. Eighteen (21.7%) had ≥1 abnormality on thrombophilia screening. The most important abnormalities which lead to treatment changes in 11 patients (13.3%) were primary anti-phospholipid syndrome (N=3; 3.6%), protein S deficiency (N=2; 2.4%) hyper-homocysteinaemia (N=6/72 screened, 8.3%). Four patients (4.8%) opted for PFO closure: two with protein S deficiency, and two with no identified thrombophilia. Seven (8.4%) had recurrent TIA/ischaemic stroke during follow-up (overall annualised incidence: 2.1%), of whom five had a PFO alone and two a PFO and IASA. DISCUSSION: Comprehensive arterial and venous thrombophilia screening is warranted in TIA/ischaemic stroke patients with a PFO±IASA, is conclusively abnormal in over a fifth, and informed important decision-making regarding individualised therapy in 13.3% of patients. The incidence of recurrent vascular events in this population is low on optimal, personalised secondary-prevention treatment, even with an underlying thrombophilia.
INTRODUCTION: Data are limited on the optimal management of cryptogenic TIA/strokepatients with a patent foramen ovale (PFO)±inter-atrial septal aneurysm (IASA), especially with an inherited thrombophilia. METHODS: Prospectively-collected data on TIA/ischaemic strokepatients with PFO, IASA or both who received 'goal-directed secondary-prevention medical treatment' were analysed. All patients had trans-oesophageal echocardiography, anti-nuclear, anti-cardiolipin, anti-beta 2 glycoprotein I antibodies, rheumatoid factor, lupus anticoagulant, protein C&S, anti-thrombin, factor VIII activity, activated protein C resistance, Factor V Leiden, prothrombin gene and MTHFR-c.677C>T mutation screening. ENA and homocysteine were assessed in the latter study period. RESULTS: Eighty-three patients were recruited. Mean follow-up: 48.1months. Forty-seven patients (56.6%) had an isolated PFO, 32 (38.6%) a PFO and an IASA, and 4 (4.8%) an IASA alone. Eighteen (21.7%) had ≥1 abnormality on thrombophilia screening. The most important abnormalities which lead to treatment changes in 11 patients (13.3%) were primary anti-phospholipid syndrome (N=3; 3.6%), protein S deficiency (N=2; 2.4%) hyper-homocysteinaemia (N=6/72 screened, 8.3%). Four patients (4.8%) opted for PFO closure: two with protein S deficiency, and two with no identified thrombophilia. Seven (8.4%) had recurrent TIA/ischaemic stroke during follow-up (overall annualised incidence: 2.1%), of whom five had a PFO alone and two a PFO and IASA. DISCUSSION: Comprehensive arterial and venous thrombophilia screening is warranted in TIA/ischaemic strokepatients with a PFO±IASA, is conclusively abnormal in over a fifth, and informed important decision-making regarding individualised therapy in 13.3% of patients. The incidence of recurrent vascular events in this population is low on optimal, personalised secondary-prevention treatment, even with an underlying thrombophilia.