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. 2012 Dec;12(6):604–605. doi: 10.7861/clinmedicine.12-6-604

Simultaneous myocardial infarction and ischaemic stroke secondary to paradoxical emboli through a patent foramen ovale

Chris Durkin 1
PMCID: PMC5922612  PMID: 23342424

Editor – Grogono et al report on an interesting patient but I do not think that they have proven the case for the association that they postulate (Clin Med August 2012 pp 391–2).1 There does not seem to be any doubt that the patient had both a myocardial infarction and a patent foramen ovale (PFO) but:

  • The presentation of the assumed stroke is atypical and there is no reported neurological abnormality after the event.

  • Lacunar infarction is an unlikely cause of seizure.

  • The images from the CT brain scan in this patient are not included in the paper, but in the absence of MRI with diffusion-weighted imaging2 I do not think that acute ischaemic stroke can be diagnosed with confidence in this case. Given that, comment about an embolic aetiology seems a matter of conjecture.

  • No distant source of thrombus was identified.

  • PFO may be found in a significant proportion of the adult population.

Is it not more likely that the patient had a transient arrhythmia and/or hypotension leading to seizure?

Regarding the subsequent approach to treatment of the PFO, the authors will be aware of the results of the CLOSURE I trial3 and a subsequent systematic review of the available literature.4

The CLOSURE I trial did not demonstrate any statistical benefit from PFO closure with a STARFlex device compared with medical treatment in patients aged 60 and under with transient ischaemic attack (TIA) or stroke. The trial did show that PFO closure with this device was associated with an increased incidence of atrial fibrillation, thereby replacing a debatable stroke risk factor with one for which there is no doubt.

References

  • 1.Grogono J. Fitzsimmons SJ. Shah BN, et al. Simultaneous myocardial infarction and ischaemic stroke secondary to paradoxical emboli through a patent foramen ovale. Clin Med. 2012;12:391–2. doi: 10.7861/clinmedicine.12-4-391. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Durkin C. Briley D. Meagher T. Diagnosis and management of transient ischaemic attack and ischaemic stroke in the acute phase. BMJ. 2011;342:d1938. doi: 10.1136/bmj.d1938. [DOI] [PubMed] [Google Scholar]
  • 3.Furlan AJ. Reisman M. Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366:991–9. doi: 10.1056/NEJMoa1009639. [DOI] [PubMed] [Google Scholar]
  • 4.Kitsios GD. Dahabreh IJ. Abu Dabrh AM, et al. Patent foramen ovale closure and medical treatments for secondary stroke prevention. A systematic review of observational and randomized evidence. Stroke. 2012;43:422–431. doi: 10.1161/STROKEAHA.111.631648. [DOI] [PMC free article] [PubMed] [Google Scholar]
Clinical Medicine. 2012 Dec;12(6):604–605.

Simultaneous myocardial infarction and ischaemic stroke secondary to paradoxical emboli through a patent foramen ovale

Joanna Grogono 1, Samantha J Fitzsimmons 2, Benoy N Shah 3, Dhrubo J Rakhit 4, Huon H Gray 5

Editor – We thank Dr Durkin for his interest in our recently published ‘Lesson of the month’. We agree that the diagnosis of paradoxical embolism cannot be made with certainty; however we wished to use this case to remind physicians to consider this as a possibility, especially in younger stroke patients. Dr Durkin correctly highlights the unusual association of lacunar cerebral infarction and seizure, and raises the possibility of transient arrhythmia and/or hypotension leading to seizure-like activity (presumably secondary to the myocardial infarction). However, we believe it is equally unlikely that a fit, active and healthy 39-year-old with no cardiovascular risk factors would suffer a large anterior myocardial infarction (MI). Additionally, the presence of an occluded left anterior descending (LAD) coronary artery and fresh thrombus in its diagonal branch – as well as neurological symptoms with confirmed cerebral infarction on CT brain scan – are all in keeping with embolic phenomena. We agree that diffusion-weighted MRI brain imaging is superior to CT scanning and acknowledge this would have been a valuable additional test.

This case occurred prior to the publication of the CLOSURE I trial1 but, as always, the risks and benefits of PFO device closure and anticoagulation were discussed with the patient. The patient is a high level competitor in martial arts, and is therefore not ideally suited to long-term anti-coagulation. The patient therefore opted for percutaneous PFO closure. The clinical value of percutaneous PFO closure has been a controversial field for many years and the release of the only randomised control trial, CLOSURE I, has failed to resolve many of the outstanding issues. However, the CLOSURE I trial has not been without its own criticism, including the long time to recruitment, the inadequate power to identify small differences between device closure and medical therapy, the high non-closure rates (15%) and the exclusion of ‘high risk’ patients or patients thought to represent the population seen in daily practice.2–4 The study does, however, remind us that vascular complications and atrial fibrillation should always be discussed with patients being considered for PFO closure.

The recently published RESPECT and PC Trials did not provide good direction on whether prevention of further stroke by PFO closure is effective, but the totality of results supports the use of PFO closure in a select group of patients at risk of secondary stroke following cryptogenic stroke.5,6

References

  • 1.Furlan AJ. Reisman M. Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366:991–9. doi: 10.1056/NEJMoa1009639. [DOI] [PubMed] [Google Scholar]
  • 2.Johnston SC. Patent foramen ovale closure-closing the door except for trials. N Engl J Med. 2012;366:1048–50. doi: 10.1056/NEJMe1201173. [DOI] [PubMed] [Google Scholar]
  • 3.Wilmshurst P. CLOSURE 1 seen through the MIST. BMJ. 2012;344:e2226. doi: 10.1136/bmj.e2226. doi: 10.1136/bmj.e222. [DOI] [PubMed] [Google Scholar]
  • 4.Guijarro C. Device closure for stroke with patent foramen ovale. N Engl J Med. 2012;366:2322. doi: 10.1056/NEJMc1204924. [DOI] [PubMed] [Google Scholar]
  • 5.Carroll JD. RESPECT. Miami, FL: 2012. Late-breaking trial preview presented at the Transcatheter Cardiovascular Therapeutics conference, October 25. [Google Scholar]
  • 6.Meier B. PC trial update. Miami, FL: 2012. Late-breaking trial preview presented at the Transcatheter Cardiovascular Therapeutics conference, October 25. [Google Scholar]

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