Increased frequency of cardioembolism and patent foramen ovale in patients with stroke and a positive travel history suggesting economy class stroke syndrome

Abstract

Objective: To investigate the frequency of acute stroke in patients with a recent travel history and to analyse risk factors, stroke patterns and presence of a patent foramen ovale (PFO) in this patient group. Design: One-year prospective observational study. Setting: Single-centre study. Methods: Enrolling all patients presenting with a first cerebral ischaemia and complementing the usual history with a standardised travel history. Results: Of 338 patients with acute stroke, 42 had a positive travel history (PTH) (12.4%). Patients with a PTH were significantly younger (56.6 (SD 13) years) than patients (66.9 (13.2) years, p = 0.0001) with a negative travel history (NTH). Frequency of PFO in the PTH group (13; 44.8%) was significantly higher than in the NTH group (7; 10.8%) (p = 0.0001), even after patients were dichotomised into two age groups (younger and older than median of all patients: 31% v 6.1%, p = 0.007 and 13.8% v 4.6%, p = 0.022, respectively). PTH patients had fewer stroke risk factors (2.2 (1.4) v 3.3 (1.6), p = 0.0001) and a different risk profile with a lower frequency of diabetes (11.9% v 31.4%, p = 0.009), hypertension (52.4% v 78.7%, p = 0.0001), atrial fibrillation (7.1% v 22%, p = 0.025) and others (16.7% v 38.9%, p = 0.005). In contrast, PTH patients had significantly more cardioembolic (35.7% v 19.3%, p = 0.023) and cryptogenic strokes (50% v 19.9%, p = 0.0001) and more often ischaemia in the territory of the posterior cerebral artery (29.6% v 6.3%, p = 0.0001). Conclusions: The finding that more PTH patients had a PFO and a cardioembolic stroke pattern but that fewer had other typical stroke risk factors led to the hypothesis that PFO is a risk factor for economy class stroke syndrome.

Posterior versus Anterior Circulation Stroke in Young Adults: A Comparative Study of Stroke Aetiologies and Risk Factors in Stroke among Young Fabry Patients (sifap1)

“…In our study, we found a higher prevalence of PFO in patients with PCS compared to those with ACS, while the presence of traditional risk factors, proportion of cardio-embolic aetiology (category TOAST 2), concomitant atrial fibrillation and coincident atrial septum aneurysms did not differ between young stroke patients with PFO and PCS compared to those with PFO and ACS. Together with the findings from SISIFO [27] and other case-control studies, which reported a higher proportion of PCS in patients with PFO than in those without PFO [34,35,36,37,38,39], our results may indicate a higher proportion of stroke attributable to PFO in PCS than in ACS.…”

Stroke after prolonged air travel associated with a pulmonary arteriovenous malformation

“…Positive travel history was defined as a travel, mainly in a sitting position, of at least 4 h in duration, and median delay between travel and stroke was 7 days. Patients with positive travel history more frequently had PFO and cardioembolic or cryptogenic strokes, and less frequently conventional stroke risk factors compared with those without travel history [8]. These findings suggest that paradoxal embolism through PFO may be a major cause for travelassociated stroke, and supports previous observations.…”

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

“…In parallel to our analysis, a recent prospective study demonstrated a higher proportion of PFO in stroke patients with PTH compared to stroke patients without positive travel history [13]. Given the higher proportion of PTH in patients with paradoxical embolism, physicians should be aware of the association between paradoxical embolism and recent PTH, not only in air travel but also in train, bus, automobile and in situations with prolonged sitting, such as in front of a computer.…”

“…Furthermore the strong association between paradoxical embolism and the presence of PTH was shown to be independent of the other examined clinical symptoms, age and sex. We defined PTH as travel of at least 4 h in duration in mainly a sitting position, in a bus, plain, train or automobile [13]. In our study PTH was found in 13.4% of patients with PFO and 3.4% patients without PFO.…”

“…weight lifting, straining for a bowel movement, vomiting, sexual intercourse, coughing) preceding the onset of focal neurological symptoms, and a history of recent prolonged travel (PTH) suggesting "Economy Class stroke syndrome" [12] during the two weeks preceding the cerebrovascular event. A positive travel history was defined as travel, mainly in a sitting position for at least 4 h in a train, car or bus [13]: 4) waking up with neurological deficit; 5) history of migraine according to International Headache Society criteria [14].…”