Patent Foramen Ovale, Ischemic Stroke and Migraine: Systematic Review and Stratified Meta-Analysis of Association Studies

Abstract

Background: Observational data have reported associations between patent foramen ovale (PFO), cryptogenic stroke and migraine. However, randomized trials of PFO closure do not demonstrate a clear benefit either because the underlying association is weaker than previously suggested or because the trials were underpowered. In order to resolve the apparent discrepancy between observational data and randomized trials, we investigated associations between (1) migraine and ischemic stroke, (2) PFO and ischemic stroke, and (3) PFO and migraine. Methods: Eligibility criteria were consistent; including all studies with specifically defined exposures and outcomes unrestricted by language. We focused on studies at lowest risk of bias by stratifying analyses based on methodological design and quantified associations using fixed-effects meta-analysis models. Results: We included 37 studies of 7,686 identified. Compared to reports in the literature as a whole, studies with population-based comparators showed weaker associations between migraine with aura and cryptogenic ischemic stroke in younger women (OR 1.4; 95% CI 0.9–2.0; 1 study), PFO and ischemic stroke (HR 1.6; 95 CI 1.0–2.5; 2 studies; OR 1.3; 95% CI 0.9–1.9; 3 studies), or PFO and migraine (OR 1.0; 95% CI 0.6–1.6; 1 study). It was not possible to look for interactions or effect modifiers. These results are limited by sources of bias within individual studies. Conclusions: The overall pairwise associations between PFO, cryptogenic ischemic stroke and migraine do not strongly suggest a causal role for PFO. Ongoing randomized trials of PFO closure may need larger numbers of participants to detect an overall beneficial effect.

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

“…The higher prevalence in our study may be due to a higher rate of performing echocardiography in sifap1 (74.8% of the total cohort [28]). A clear association between PFO and cryptogenic stroke is well established in case-control studies [29,30] but not in cohort studies on asymptomatic individuals with PFO [30,31]. Hence, some individuals with PFO are obviously at high risk for paradoxical embolism or embolism of in situ atrial thrombi, but their effect on the overall stroke risk in the general population is negligible [27,31].…”

Brain abscess associated with patent foramen ovale

“…The following clinical data were collected: (1) age and gender, (2) transthoracic echocardiography (TTE) findings, (3) TEE findings, (4) location of the abscess, (5) pathogenic bacteria, (6) surgical or conservative treatment, (7) what antibiotics were administered and for how long, (8) presence of odontopathy, (9) immunosuppression or other predisposing factors, and (10) outcomes.…”

“…In patients with right-to-left shunt, the accumulation of a bacterial mass without trapping in the pulmonary microcirculation may embolize to the cerebral microcirculation to cause a brain abscess. We hypothesize that patent foramen ovale (PFO), which is a wellknown right-to-left shunt disease [7,22,24], may be one of the etiologies of brain abscess. Several reports have described the presentation of brain abscesses with PFO, but all were reports of one or two cases, and there have been no reports as to whether or not PFO exists for a series of patients with CBA.…”

Migraine and the risk of stroke

“…[32][33][34][35][36] Whether this is a casual association or a link due to common stroke comorbidities remain to be determined. 36 Mechanism of increased risk of CI in PFO and migraine is not well understood.…”