Original Article
Patent Foramen Ovale and Cryptogenic Stroke in Older Patients
N Engl J Med 2007; 357:2262-2268November 29, 2007
- Abstract
Background
Studies to date have shown an association between the presence of patent foramen ovale and cryptogenic stroke in patients younger than 55 years of age. This association has not been established in patients 55 years of age or older.
Methods
We prospectively examined 503 consecutive patients who had had a stroke, and we compared the 227 patients with cryptogenic stroke and the 276 control patients with stroke of known cause. We examined the prevalences of patent foramen ovale and of patent foramen ovale with concomitant atrial septal aneurysm in all patients, using transesophageal echocardiography. We also compared data for the 131 younger patients (<55 years of age) and those for the 372 older patients (≥55 years of age).
Results
The prevalence of patent foramen ovale was significantly greater among patients with cryptogenic stroke than among those with stroke of known cause, for both younger patients (43.9% vs. 14.3%; odds ratio, 4.70; 95% confidence interval [CI], 1.89 to 11.68; P<0.001) and older patients (28.3% vs. 11.9%; odds ratio, 2.92; 95% CI, 1.70 to 5.01; P<0.001). Even stronger was the association between the presence of patent foramen ovale with concomitant atrial septal aneurysm and cryptogenic stroke, as compared with stroke of known cause, among both younger patients (13.4% vs. 2.0%; odds ratio, 7.36; 95% CI, 1.01 to 326.60; P=0.049) and older patients (15.2% vs. 4.4%; odds ratio, 3.88; 95% CI, 1.78 to 8.46; P<0.001). Multivariate analysis adjusted for age, plaque thickness, and presence or absence of coronary artery disease and hypertension showed that the presence of patent foramen ovale was independently associated with cryptogenic stroke in both the younger group (odds ratio, 3.70; 95% CI, 1.42 to 9.65; P=0.008) and the older group (odds ratio, 3.00; 95% CI, 1.73 to 5.23; P<0.001).
Conclusions
There is an association between the presence of patent foramen ovale and cryptogenic stroke in both older patients and younger patients. These data suggest that paradoxical embolism is a cause of stroke in both age groups.
Media in This Article
Figure 1
Prevalences of Patent Foramen Ovale (PFO) and PFO with Concomitant Atrial Septal Aneurysm among Patients with Cryptogenic Stroke and Those with Stroke of Known Cause, According to Age Group.Figure 2
Odds Ratios for the Presence of Patent Foramen Ovale among Patients with Cryptogenic Stroke, as Compared with Those with Stroke of Known Cause.Article Activity
- Article
The cause of stroke remains unidentified by routine diagnostic testing in about 40% of patients.1 One potential cause of embolic stroke is a patent foramen ovale, which enables right-to-left intracardiac shunting. The foramen ovale remains open in about one fourth of the general population. The prevalence decreases gradually with increasing age, from 34% during the first three decades to 20% during the ninth decade.2
An association between the presence of patent foramen ovale and cryptogenic stroke has been reported; however, the study populations consisted primarily of younger patients.3-6 Only a few studies have included older patients.7-9 A meta-analysis showed that the presence of patent foramen ovale in patients younger than 55 years of age is significantly associated with cryptogenic stroke, but the relationship has remained unconfirmed in patients 55 years of age or older.10 Proof of a significant relationship would have implications for diagnostic and therapeutic management.
The objectives of our study were to clarify whether there is a significant association between the presence of patent foramen ovale and cryptogenic stroke in patients 55 years of age or older and to compare the findings with those for younger patients. Our study population included all consecutive patients 18 to 85 years of age who were admitted to our stroke unit or our neurologic intensive care unit. We examined all patients for the presence or absence of patent foramen ovale, using transesophageal echocardiography.
Methods
Study Population
A total of 596 consecutive patients admitted to our stroke unit or neurologic intensive care unit fulfilled the inclusion criteria of an age of 18 to 85 years and the presence of suspected acute brain ischemia. These patients were enrolled in the study during the 16-month period between January 2001 and April 2002. Written informed consent was obtained from each patient or, if the patient was incapable of providing consent, from the patient's relatives. The study was approved by the local ethics committee.
Thirty-seven patients were excluded from analyses because transesophageal echocardiography could not be performed: 10 were too ill to undergo the procedure, 10 were transferred to another clinic or died before the procedure could be performed, 14 had an uncontrollable gag reflex or gastrointestinal tract obstruction that precluded our performing the procedure, and 3 had undergone the procedure in another clinic but the method of data acquisition was inconsistent with our protocol. An additional 24 patients declined transesophageal echocardiography. Another 32 patients were excluded from analyses because their diagnosis on discharge was other than brain ischemia. Our analyses focused on the remaining 503 patients.
The following routine diagnostic tests were performed in all patients: cranial computed tomography, magnetic resonance imaging (MRI) of the brain, or both; and duplex sonography of the extracranial and intracranial arteries with a 4- to 7-MHz linear-array scanner (model ATL HDI 5000/3500, Advanced Technology Laboratories). The degree of stenosis of the internal carotid artery was defined according to the European Carotid Surgery Trial protocol.11 Angiographic imaging of the intracranial and vertebrobasilar arteries was performed in 231 patients (45.9%), by means of time-of-flight angiography in patients who underwent MRI or by means of digital subtraction angiography before intraarterial thrombolysis therapy in the remaining patients. Angiography was not performed in 272 patients (54.1%). All patients underwent transthoracic echocardiography and electrocardiography. In patients with suspected paroxysmal atrial fibrillation (those with palpitations or a history of atrial fibrillation) or ambiguous results of routine diagnostic tests, we also performed 24-hour Holter monitoring.
Before transesophageal echocardiography was performed, we classified the cause of infarction according to the modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.12 The classification was done in advance to make possible a comparison of our data and those from earlier studies of the role of patent foramen ovale in stroke.10 The TOAST classification subdivides the cause of stroke into five subtypes, on the basis of clinical features and the results of diagnostic tests: large-artery atherosclerosis, cardioembolism, small-vessel occlusion, stroke of other known cause, and stroke of unknown cause. The patients with stroke whose cause was classified as one of the four known-cause subtypes were assigned to the known-cause group in our study. We deviated from the original TOAST criteria by assigning patients with two or more causes of stroke to the known-cause group. Patients with stroke of causes that were unknown despite extensive routine diagnostic testing before transesophageal echocardiography were assigned to our cryptogenic-stroke group.
Echocardiographic Examinations
An ultrasonography system (ATL HDI 3500) was used for transthoracic examinations (with a 2-MHz transducer) and transesophageal examinations (with a 5-MHz transducer). Routine transthoracic echocardiography of the heart was performed in each patient. Within a median of 2 days after stroke onset (mean ±SD, 3±2), all patients underwent transesophageal echocardiography. A contrast agent (oxypolygelatin [Gelifundol, Biotest]) was injected while the patient was at rest and while a Valsalva maneuver was performed. Patent foramen ovale was diagnosed when microbubbles were detected in the left atrium within four cycles after right-atrial opacification. Atrial septal aneurysm was diagnosed when the excursion of an abnormally redundant and mobile atrial septum was over 10 mm.13 The ascending aorta and the aortic arch, including the outlet of the left subclavian artery, were examined for aortic plaques. The thickest plaque was considered for classification.14
Statistical Analysis
Data are presented as means ±SD for continuous variables and as absolute numbers and relative percentages for categorical variables. Group comparisons were performed by means of the Wilcoxon rank-sum test for continuous variables and Fisher's exact test for categorical variables. Univariate and multivariate logistic-regression analyses were used to estimate the unadjusted and adjusted odds ratios and the corresponding 95% confidence intervals. The characteristics that affected the univariate analysis were included in the multivariable models: age, plaque thickness, presence or absence of coronary artery disease, and presence or absence of hypertension. All statistical tests were two-sided, and P values of less than 0.05 were considered to indicate statistical significance. All analyses were performed with the SAS statistical package (version 8.2).
Results
Baseline Characteristics
The overall age range of the patients was 20 to 84 years (mean, 62.2±13.1). Of the 503 patients, 131 (26.0%) were younger than 55 years of age (mean, 45.3±8.3), and 372 (74.0%) were 55 years of age or older (mean, 68.0±7.0). The cause of stroke could be identified by means of routine diagnostic testing in 276 patients (54.9%). The stroke was classified as cryptogenic in the remaining 227 patients (45.1%), including 82 of the 131 patients younger than 55 years of age (62.6%) and 145 of the 372 patients 55 years of age or older (39.0%). As compared with the patients with stroke of known cause, the patients with cryptogenic stroke were on average 6 years younger and more of them had patent foramen ovale with or without a concomitant atrial septal aneurysm (Table 1Table 1
Baseline Characteristics of Patients with Cryptogenic Stroke or with Stroke of Known Cause.). On the other hand, patients with cryptogenic stroke had a lower prevalence of coronary artery disease or hypertension and slightly thinner aortic plaques than patients with stroke of known cause. There were no significant differences between the two groups with regard to sex or the presence or absence of diabetes, hyperlipidemia, history of smoking, or peripheral artery disease.Association between Patent Foramen Ovale and Cryptogenic Stroke
The prevalence of patent foramen ovale was significantly greater among patients with cryptogenic stroke than among patients with stroke of known cause. This held true both for patients younger than 55 years of age (43.9% vs. 14.3%, P<0.001) and for patients 55 years of age or older (28.3% vs. 11.9%, P<0.001) (Figure 1AFigure 1
Prevalences of Patent Foramen Ovale (PFO) and PFO with Concomitant Atrial Septal Aneurysm among Patients with Cryptogenic Stroke and Those with Stroke of Known Cause, According to Age Group.). The prevalence of patent foramen ovale with concomitant atrial septal aneurysm was also greater among patients with cryptogenic stroke than among those with stroke of known cause, both in the younger group (13.4% vs. 2.0%, P=0.03) and in the older group (15.2% vs. 4.4%, P<0.001) (Figure 1B). In the unadjusted univariate analysis, the odds ratios for patients younger than 55 years of age with cryptogenic stroke, as compared with stroke of known cause, were 4.70 (95% confidence interval [CI], 1.89 to 11.68; P<0.001) for the presence of patent foramen ovale and 7.36 (95% CI, 1.01 to 326.60; P=0.049) for the presence of patent foramen ovale with concomitant atrial septal aneurysm. Among patients 55 years of age or older, the odds ratios were smaller: 2.92 (95% CI, 1.70 to 5.01; P<0.001) for the presence of patent foramen ovale and 3.88 (95% CI, 1.78 to 8.46; P<0.001) for the presence of patent foramen ovale with concomitant atrial septal aneurysm. In the multivariate analysis, the presence of patent foramen ovale was independently associated with cryptogenic stroke (Figure 2Figure 2Odds Ratios for the Presence of Patent Foramen Ovale among Patients with Cryptogenic Stroke, as Compared with Those with Stroke of Known Cause.), both in the overall study population and in the younger and older groups. In contrast to the unadjusted odds ratios from the univariate analysis, the adjusted odds ratios from the multivariate analysis showed only a slight difference in the prevalence of patent foramen ovale among patients with cryptogenic stroke, as compared with stroke of known cause, in the younger group (odds ratio, 3.70; P=0.008) and the older group (odds ratio, 3.00; P<0.001).Among patients 55 years of age or older with cryptogenic stroke, atherosclerotic plaque thickness was significantly less in patients with patent foramen ovale (2.78±1.56 mm) and in those with patent foramen ovale with concomitant atrial septal aneurysm (2.64±1.36 mm) than in patients without patent foramen ovale (3.65±1.95 mm) (Figure 3Figure 3
Mean Thickness of Atherosclerotic Plaque in Patients 55 Years of Age or Older with Cryptogenic Stroke.). These three subgroups did not differ significantly with respect to mean age (67.8±8.0 years, 68.6±8.0 years, and 67.9±7.0 years, respectively; P=0.81). Among patients 55 years of age or older, the multivariate analysis also showed a nearly significant relationship between the thickness of the aortic plaque and the risk of cryptogenic stroke (odds ratio for patients with cryptogenic stroke vs. stroke of known cause, 1.15 per 1-mm increase in plaque thickness; 95% CI, 1.00 to 1.31; P=0.05).Discussion
We found an association between the presence of patent foramen ovale and cryptogenic stroke, not only in patients younger than 55 years of age but also in those 55 years of age or older. The relationship between the presence of patent foramen ovale and cryptogenic stroke was even more pronounced among patients who had concomitant atrial septal aneurysm. Moreover, multivariate analysis showed that the presence of a patent foramen ovale was independently associated with cryptogenic stroke in both age groups.
Previous studies have been limited by selection bias, with older patients undergoing transesophageal echocardiography less often than younger patients.10 In our study, transesophageal echocardiography was performed for all patients. The prevalence of cryptogenic stroke in our study was relatively high, at 45%. However, we classified the cause of stroke before transesophageal echocardiography was performed, as was done in a recently published study.15 Two studies that reported prevalences of cryptogenic stroke lower than those in our study used available data from transesophageal echocardiography to classify the cause of stroke.16,17 We may have slightly overestimated the prevalence of cryptogenic stroke, because magnetic resonance angiography or digital subtraction angiography was performed in only about half the patients. As a result, some patients with intracranial large-artery atherosclerosis may have been erroneously assigned to the cryptogenic-stroke group.
It has long been debated whether the presence of patent foramen ovale actually does play a causal role in stroke or whether there is only a noncausal statistical relationship. However, there is considerable evidence18 that a patent foramen ovale can cause ischemic stroke, by means of paradoxical embolism. A positive relationship has been shown between the size of the shunt and the risk of stroke,19 patients with a residual shunt after occlusion of the patent foramen ovale have an increased rate of recurrence of stroke,20 the rate of stroke is increased among patients with pulmonary embolism and a patent foramen ovale,21 and the migration of a thrombus through the patent foramen ovale can be directly visualized repeatedly,22 even in very elderly patients.23,24 The relationship is still controversial with respect to older patients,25 because the available data are contradictory and are based on studies that used different diagnostic tests.7-9 In a study involving transthoracic echocardiography, Di Tullio et al. reported an increased prevalence of patent foramen ovale in all age groups with cryptogenic stroke.7 In one study using transesophageal echocardiography, and another using transcranial Doppler ultrasonography, for detection of right-to-left shunting after administration of contrast agent, there were no significant associations between the presence of patent foramen ovale and cryptogenic stroke.8,9 Data from these studies were insufficient to draw a conclusion for older patients with cryptogenic stroke.10
In addition to the significant association found in our study, additional considerations provide support for the hypothesis that patent foramen ovale plays a role in stroke in older patients. With increasing age, there is an increasing potential for paradoxical embolism,26 since the incidence of venous thromboembolism increases exponentially with increasing age.27 The combination of more frequent formation of thromboembolic material and hemodynamic changes promoting right-to-left shunting could contribute to an increased probability of paradoxical embolism in older patients.28 A recent retrospective analysis showed that the presence of patent foramen ovale increases the risk of adverse events in older patients with cryptogenic stroke who are receiving aspirin or warfarin, but not in younger patients.28 In addition, the diameter of the patent foramen ovale increases with age,2 and this could make older patients more susceptible to paradoxical embolism.7
The question of causality between the presence of patent foramen ovale and stroke is, however, more difficult to answer with regard to older patients than with regard to younger patients, since older patients frequently have additional potential sources of emboli, such as atherosclerosis of the aorta.29 This lends particular importance to the observation in our study that older patients with cryptogenic stroke and patent foramen ovale had significantly less severe atherosclerosis of the aortic arch than did patients without patent foramen ovale. The probability that the ischemia in the subgroup with patent foramen ovale is due to embolism from the aortic arch is correspondingly smaller, since the risk of embolism correlates with plaque thickness.29
Consistent with other reports, our study showed a lower prevalence of patent foramen ovale in older patients with cryptogenic stroke than in younger patients.15 In addition to the fact that alternative causes should be taken into account in older patients, it should be considered that the prevalence of patent foramen ovale decreases linearly with increasing age.2 On the other hand, the numbers of patients with patent foramen ovale and concomitant atrial septal aneurysm who were younger than 55 years of age and who were 55 years of age or older were similar in both the cryptogenic-stroke group (13.4% and 15.2%, respectively) and the known-cause group (2.0% and 4.4%, respectively). Di Tullio et al. reported a low prevalence of patent foramen ovale with concomitant atrial septal aneurysm (1.7%) in the general population.30 In a study of patients 55 years of age or younger, Mas et al. found that the presence of patent foramen ovale with concomitant atrial septal aneurysm is associated with a high risk of paradoxical embolism.13 Our data suggest that the presence of patent foramen ovale with concomitant atrial septal aneurysm is a high-risk characteristic in older patients as well.
In summary, our results show an association between the presence of patent foramen ovale and cryptogenic stroke in both patients younger than 55 years of age and those 55 years of age or older. There are no clear guidelines based on randomized trials for therapy if patent foramen ovale is present. There are several ongoing randomized studies (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment [RESPECT] trial, Evaluation of the STARFlex Septal Closure System in Patients with a Stroke or TIA due to the Possible Passage of Clot of Unknown Origin through a Patent Foramen Ovale [CLOSURE-1], and PC [Percutaneous Closure]-Trial: Patent Foramen Ovale and Cryptogenic Embolism); their results may clarify the effectiveness of percutaneous closure as compared with medical therapy. However, the patients in all three trials are 60 years of age or younger on enrollment, and studies that include older patients are needed to develop diagnostic and therapeutic management strategies for this large group of patients.
No potential conflict of interest relevant to this article was reported.
Drs. Handke and Harloff contributed equally to this article.
Source Information
From the Departments of Cardiology and Angiology (M.H., A.G.), Neurology and Neurophysiology (A. Harloff, A. Hetzel), and Medical Biometry and Statistics (M.O.), University Hospital Freiburg, Freiburg, Germany.
Address reprint requests to Dr. Handke at the Department of Cardiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland, or at handkem@uhbs.ch.
- References
References
1
Sacco RL ,Ellenberg JH ,Mohr JP , et al. Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989;25:382-390
CrossRef | Web of Science | Medline2
Hagen PT ,Scholz DG ,Edwards WD . Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17-20
Web of Science | Medline3
Lechat P ,Mas JL ,Lascault G , et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988;318:1148-1152
Full Text | Web of Science | Medline4
Webster MW ,Chancellor AM ,Smith HJ , et al. Patent foramen ovale in young stroke patients. Lancet 1988;2:11-12
CrossRef | Web of Science | Medline5
Cabanes L ,Mas JL ,Cohen A , et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age: a study using transesophageal echocardiography. Stroke 1993;24:1865-1873
CrossRef | Web of Science | Medline6
Job FP ,Ringelstein EB ,Grafen Y , et al. Comparison of transcranial contrast Doppler sonography and transesophageal contrast echocardiography for the detection of patent foramen ovale in young stroke patients. Am J Cardiol 1994;74:381-384
CrossRef | Web of Science | Medline7
Di Tullio M ,Sacco RL ,Gopal A ,Mohr JP ,Homma S . Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992;117:461-465
Web of Science | Medline8
Jones EF ,Calafiore P ,Donnan GA ,Tonkin AM . Evidence that patent foramen ovale is not a risk factor for cerebral ischemia in the elderly. Am J Cardiol 1994;74:596-599
CrossRef | Web of Science | Medline9
Yeung M ,Khan KA ,Shuaib A . Transcranial Doppler ultrasonography in the detection of venous to arterial shunting in acute stroke and transient ischaemic attacks. J Neurol Neurosurg Psychiatry 1996;61:445-449
CrossRef | Web of Science | Medline10
Overell JR ,Bone I ,Lees KR . Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000;55:1172-1179
Web of Science | Medline11
MRC European Carotid Surgery Trialists' Collaborative Group
CrossRef | Web of Science | Medline12
Adams HP Jr ,Bendixen BH ,Kappelle LJ , et al. Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. Stroke 1993;24:35-41
CrossRef | Web of Science | Medline13
Mas JL ,Arquizan C ,Lamy C , et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001;345:1740-1746
Full Text | Web of Science | Medline14
The French Study of Aortic Plaques in Stroke Group
Full Text | Web of Science | Medline15
De Castro S ,Rasura M ,Di Angelantonio E , et al. Distribution of potential sources of embolism in young and older stroke patients: implications for recurrent vascular events. J Cardiovasc Med (Hagerstown) 2006;7:191-196
CrossRef | Web of Science | Medline16
Petty GW ,Brown RD Jr ,Whisnant JP ,Sicks JD ,O'Fallon WM ,Wiebers DO . Ischemic stroke subtypes: a population-based study of incidence and risk factors. Stroke 1999;30:2513-2516
CrossRef | Web of Science | Medline17
Kolominsky-Rabas PL ,Weber M ,Gefeller O ,Neundoerfer B ,Heuschmann PU . Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 2001;32:2735-2740
CrossRef | Web of Science | Medline18
Windecker S ,Wahl A ,Nedeltchev K , et al. Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. J Am Coll Cardiol 2004;44:750-758
CrossRef | Web of Science | Medline19
Stone DA ,Godard J ,Corretti MC , et al. Patent foramen ovale: association between the degree of shunt by contrast transesophageal echocardiography and the risk of future ischemic neurologic events. Am Heart J 1996;131:158-161
CrossRef | Web of Science | Medline20
Wahl A ,Meier B ,Haxel B , et al. Prognosis after percutaneous closure of patent foramen ovale for paradoxical embolism. Neurology 2001;57:1330-1332
Web of Science | Medline21
Kasper W ,Geibel A ,Tiede N ,Just H . Patent foramen ovale in patients with haemodynamically significant pulmonary embolism. Lancet 1992;340:561-564
CrossRef | Web of Science | Medline22
Kessel-Schaefer A ,Lefkovits M ,Zellweger MJ , et al. Migrating thrombus trapped in a patent foramen ovale. Circulation 2001;103:1928-1928
Web of Science | Medline23
Iwanaga T ,Iguchi Y ,Shibazaki K ,Inoue T ,Kimura K . Paradoxical brain embolism in an acute stroke. J Neurol Sci 2007;254:102-104
CrossRef | Web of Science | Medline24
Fraticelli A ,Gambini C ,Iannoni E ,Paciaroni E . Impending paradoxical embolism through a patent foramen ovale in an octogenarian with pulmonary embolism: detection by transesophageal echocardiography and successful treatment by anticoagulation. Arch Gerontol Geriatr 1998;27:41-47
CrossRef | Web of Science | Medline25
Nomura E ,Matsumoto M . Cerebral infarction and patent foramen ovale (PFO) in the elderly: is PFO the culprit or not? Intern Med 2005;44:401-402
CrossRef | Web of Science | Medline26
Meier B . Patent foramen ovale, guilty but only as a gang member and for a lesser crime. J Am Coll Cardiol 2006;47:446-448
CrossRef | Web of Science | Medline27
Anderson FA Jr ,Wheeler HB ,Goldberg RJ , et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism: the Worcester DVT Study. Arch Intern Med 1991;151:933-938
CrossRef | Web of Science | Medline28
Homma S ,DiTullio MR ,Sacco RL ,Sciacca RR ,Mohr JP . Age as a determinant of adverse events in medically treated cryptogenic stroke patients with patent foramen ovale. Stroke 2004;35:2145-2149
CrossRef | Web of Science | Medline29
Amarenco P ,Cohen A ,Tzourio C , et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994;331:1474-1479
Full Text | Web of Science | Medline30
Di Tullio MR ,Sacco RL ,Sciacca RR ,Jin Z ,Homma S . Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J Am Coll Cardiol 2007;49:797-802
CrossRef | Web of Science | Medline
- Citing Articles (102)
Citing Articles
1
Carlos A. C. Pedra, Simone R. Fontes Pedra. 2012. Atrial Level Shunts Including Partial Anomalous Pulmonary Venous Connection and Scimitar Syndrome. , 289-307.
CrossRef2
Vincent Chow, William Wang, Michael Wilson, John Yiannikas. (2012) Thrombus in transit within a patent foramen ovale: An argument for consideration of prophylactic closure?. Journal of Clinical Ultrasound 40:2, 115-118
CrossRef3
Kazuto Kobayashi, Kazumi Kimura, Yasuyuki Iguchi, Kenichirou Sakai, Junya Aoki, Takeshi Iwanaga, Kensaku Shibazaki. (2012) Right-to-Left-Shunt Detected by c-TCD Using the Orbital Window in Comparison with Temporal Bone Windows. Journal of Neuroimaging 22:1, 80-84
CrossRef4
F. Praz, S. Beney, A. Wahl, S. Windecker, B. Meier. (2012) Long-term follow-up after percutaneous closure of patent foramen ovale for secondary prevention of paradoxical embolism in elderly patients (≥70 years). European Geriatric Medicine
CrossRef5
C. Brasselet, S. Duval. (2011) Quels foramens ovales perméables faut-il fermer et comment ?. Annales de Cardiologie et d'Angéiologie 60:6, 366-372
CrossRef6
Xiaoyan Gu, Yihua He, Zhian Li, Michael C. Kontos, Walter H.J. Paulsen, James A. Arrowood, J.V. (Ian) Nixon. (2011) Comparison of Frequencies of Patent Foramen Ovale and Thoracic Aortic Atherosclerosis in Patients With Cryptogenic Ischemic Stroke Undergoing Transesophageal Echocardiography. The American Journal of Cardiology 108:12, 1815-1819
CrossRef7
Erwin Martín Hernandez Ocampo, Josep María Aragonés Pascual. (2011) Ictus de repetición por embolia paradójica tras colocación de prótesis articular. Revista Española de Geriatría y Gerontología
CrossRef8
Demosthenes G. Katritsis. (2011) Transseptal puncture through atrial septal closure devices. Heart Rhythm 8:11, 1676-1677
CrossRef9
Dilek Kosehan, Kayihan Akin, Asli Koktener, Banu Cakir, Ayse Aktas, Mehmet Teksam. (2011) Interatrial shunt: diagnosis of patent foramen ovale and atrial septal defect with 64-row coronary computed tomography angiography. Japanese Journal of Radiology 29:8, 576-582
CrossRef10
Yasufumi Kijima, Teiji Akagi, Manabu Taniguchi, Koji Nakagawa, Kentaro Deguchi, Tomoko Tomii, Kengo Kusano, Shunji Sano, Hiroshi Ito. (2011) Catheter closure of atrial septal defect in patients with cryptogenic stroke: initial experience in Japan. Cardiovascular Intervention and Therapeutics
CrossRef11
Emiliano De Marchis, Silvia Di Legge, Fabrizio Sallustio, Paolo Stanzione, Mauro Borzi, Francesco Romeo. (2011) Cryptogenic cerebral ischemia. Journal of Cardiovascular Medicine 12:8, 530-537
CrossRef12
William David Freeman, Maria I. Aguilar. (2011) Prevention of Cardioembolic Stroke. Neurotherapeutics 8:3, 488-502
CrossRef13
S. Gallerini, B. Calchetti, C. Cianchi, A. M. Troia, R. Madonna, A. Cresti, M. Mancuso. (2011) Can patent foramen ovale affect rehabilitation? The uncommon association of platypnea-orthodeoxia syndrome and stroke. Neurological Sciences 32:3, 513-514
CrossRef14
Justin G. Luermans, Werner Budts, Jurriën M. Ten Berg, Herbert W. Plokker, Maarten J. Suttorp, Martijn C. Post. (2011) Comparison of outcome after patent foramen ovale closure in older versus younger patients. EuroIntervention 7:2, 209-215
CrossRef15
Junya Aoki, Kazumi Kimura, Yasuyuki Iguchi, Kensaku Shibazaki, Kenichiro Sakai, Yuka Terasawa, Yuki Sakamoto. (2011) Higher LA pressure may prevent opening of patent foramen ovale in acute ischemic stroke patients with atrial fibrillation. Journal of the Neurological Sciences 304:1-2, 111-116
CrossRef16
Catherine N. Dao, Jonathan M. Tobis. (2011) PFO and paradoxical embolism producing events other than stroke. Catheterization and Cardiovascular Interventions 77:6, 903-909
CrossRef17
Cyril Pellaton, Raphaël Heinzer, Patrik Michel, Eric Eeckhout. (2011) Patent foramen ovale and obstructive sleep apnoea: From pathophysiology to diagnosis of a potentially dangerous association. Archives of Cardiovascular Diseases 104:4, 242-251
CrossRef18
Hiroto Suzuyama, Eiji Taguchi, Shinzo Miyamoto, Toshiaki Nuki, Masatsugu Nozoe, Tadashi Sawamura, Tomohiro Sakamoto, Koichi Nakao. (2011) A case of acute coronary syndrome caused by a giant saddle thrombus at left main coronary artery bifurcation. Journal of Cardiology Cases 3:2, e86-e89
CrossRef19
Patrick A. Calvert, Bushra S. Rana, Anna C. Kydd, Leonard M. Shapiro. (2011) Patent foramen ovale: anatomy, outcomes, and closure. Nature Reviews Cardiology 8:3, 148-160
CrossRef20
C. Hamilton-Craig, A. Sestito, L. Natale, A. Meduri, P. Santangeli, F. Infusino, F. Pilato, V. Di Lazzaro, F. Crea, G. A. Lanza. (2011) Contrast transoesophageal echocardiography remains superior to contrast-enhanced cardiac magnetic resonance imaging for the diagnosis of patent foramen ovale. European Journal of Echocardiography 12:3, 222-227
CrossRef21
Hee-Kwon Park, Seo-Young Lee, Seong-Eun Kim, Chang-Ho Yun, Sung Hun Kim. (2011) Small deep white matter lesions are associated with right-to-left shunts in migraineurs. Journal of Neurology 258:3, 427-433
CrossRef22
Annabelle Lao, Cindy J. Fuller, Jill T. Jesurum. 2011. Transcranial Doppler in the Detection and Quantitation of Patent Foramen Ovale and Other Right-to-Left Circulatory Shunts. , 187-197.
CrossRef23
J. O. Na, S. Y. Shin, H. E. Lim, C. U. Choi, S. H. Kim, J. W. Kim, E. J. Kim, E. M. Lee, S.-W. Rha, C. G. Park, H. S. Seo, D. J. Oh, Y.-H. Kim. (2011) Impaired transport function of the left atrium and left atrial appendage in cryptogenic stroke patients with atrial septal aneurysm and without patent foramen ovale. European Journal of Echocardiography 12:2, 140-147
CrossRef24
Fabrizio Sallustio, Silvia Di Legge, Marina Diomedi, Paolo Stanzione. (2011) Effect of a Single Oral Dose of Sildenafil on Right-to-Left Shunt. Cerebrovascular Diseases 32:3, 296-297
CrossRef25
David M. Greer, Shunichi Homma, Karen L. Furie. 2011. Cardiac Diseases. , 814-827.
CrossRef26
Maria I. Aguilar, Oscar R. Benavente. 2011. Secondary Prevention of Cardioembolic Stroke. , 1173-1191.
CrossRef27
Bruce Irwin, Simon Ray. (2011) Patent Foramen Ovale-Assessment and Treatment. Cardiovascular Therapeuticsno-no
CrossRef28
David M Kent, David E Thaler, . (2011) The Risk of Paradoxical Embolism (RoPE) Study: Developing risk models for application to ongoing randomized trials of percutaneous patent foramen ovale closure for cryptogenic stroke. Trials 12:1, 185
CrossRef29
Rodica Elena Petrea, Feliks Koyfman, Aleksandra Pikula, Jose Rafael Romero, Jason Viereck, Viken L. Babikian, Carlos S. Kase, Thanh N. Nguyen. (2011) Acute Stroke, Catheter Related Venous Thrombosis, and Paradoxical Cerebral Embolism: Report of Two Cases. Journal of Neuroimagingno-no
CrossRef30
Silvia Di Legge, Fabrizio Sallustio, Emiliano De Marchis, Costanza Rossi, Giacomo Koch, Marina Diomedi, Mauro Borzi, Francesco Romeo, Paolo Stanzione. (2011) Short-Term and Two-Year Rate of Recurrent Cerebrovascular Events in Patients with Acute Cerebral Ischemia of Undetermined Aetiology, with and without a Patent Foramen Ovale. ISRN Neurology 2011, 1-6
CrossRef31
Danilo Toni, Ralph L. Sacco, Michael Brainin, J.P. Mohr. 2011. Classification of Ischemic Stroke. , 293-306.
CrossRef32
2011. Clinical Methods for Sclerotherapy of Varicose Veins. , 238-281.
CrossRef33
P. Davison, P. F. Clift, R. P. Steeds. (2010) The role of echocardiography in diagnosis, monitoring closure and post-procedural assessment of patent foramen ovale. European Journal of Echocardiography 11:10, i27-i34
CrossRef34
Aylin Tugcu, Kazue Okajima, Zhezhen Jin, Tatjana Rundek, Shunichi Homma, Ralph L. Sacco, Mitchell S.V. Elkind, Marco R. Di Tullio. (2010) Septal Pouch in the Left Atrium and Risk of Ischemic Stroke. JACC: Cardiovascular Imaging 3:12, 1276-1283
CrossRef35
Stefano De Castro, Federica Papetti, Emanuele Di Angelantonio, Biljana Razmovska, Giovanni Truscelli, Ursula Tuderti, Emanuele Puca, Agata Correnti, Marco Fiorelli, Massimiliano Prencipe, Danilo Toni. (2010) Feasibility and Clinical Utility of Transesophageal Echocardiography in the Acute Phase of Cerebral Ischemia. The American Journal of Cardiology 106:9, 1339-1344
CrossRef36
Mouhammad A. Jumaa, Lawrence R. Wechsler. (2010) Management of Patent Foramen Ovale and Stroke. Current Treatment Options in Neurology 12:6, 483-491
CrossRef37
P. E. Cotter, M. Belham, P. J. Martin. (2010) Stroke in younger patients: the heart of the matter. Journal of Neurology 257:11, 1777-1787
CrossRef38
P. A. Ringleb, M.-G. Bousser, G. Ford, P. Bath, M. Brainin, V. Caso, Á. Cervera, A.l Chamorro, Charlotte Cordonnier, L. Csiba, A. Davalos, H.-C. Diener, J. Ferro, W. Hacke, M. Hennerici, M. Kaste, P. Langhorne, K. Lees, D. Leys, J. Lodder, H. S. Markus, J.-L. Mas, H. P. Mattle, K. Muir, B. Norrving, V. Obach, S. Paolucci, E. B. Ringelstein, P. D. Schellinger, J. Sivenius, V. Skvortsova, K. Stibrant Sunnerhagen, L. Thomassen, D. Toni, R.r von Kummer, N. Gunnar Wahlgren, M. F. Walker, J. Wardlaw. 2010. Ischaemic Stroke and Transient Ischaemic Attack. , 101-158.
CrossRef39
Nishant Gupta, Chris Lau, Anthony Al-Dehneh, Joseph Daoko, Aman Vazir, Rupen Parikh, Anuj Agarwal, Will Newton, Wishwdeep Dhillon, Isha Gupta, Dipak Pandya, Vincent A. DeBari, Aiman Hamdan, Fayez Shamoon, Mahesh Bikkina. (2010) Importance of Performing Transesophageal Echocardiography in Acute Stroke Patients older than Fifty. Echocardiography 27:9, 1086-1092
CrossRef40
Ulrich Laufs, Uta C. Hoppe, Stephan Rosenkranz, Paulus Kirchhof, Michael Böhm, Hans-Christoph Diener, Matthias Endres, Martin Grond, Werner Hacke, Thomas Meinertz, E. Bernd Ringelstein, Joachim Röther, Martin Dichgans. (2010) Cardiological evaluation after cerebral ischaemia. Clinical Research in Cardiology 99:10, 609-625
CrossRef41
Rui Andre Providencia. (2010) Headache and cardiovascular disease: old symptoms, new proposals. Future Cardiology 6:5, 703-723
CrossRef42
Christian Spies, Qi-Ling Cao, Ziyad M Hijazi. (2010) Transcatheter patent foramen ovale closure: review and choice of devices. Interventional Cardiology 2:4, 601-614
CrossRef43
James D. Marsh, Salah G. Keyrouz. (2010) Stroke Prevention and Treatment. Journal of the American College of Cardiology 56:9, 683-691
CrossRef44
G. P. ANZOLA, L. GIUSTI DEL GIARDINO, M.P. PIRAS. (2010) Patent foramen ovale (PFO) and cryptogenic stroke. Journal of Thrombosis and Haemostasis 8:8, 1675-1677
CrossRef45
Graeme C. Elliott, Muralidharan Sargurupremraj, Uma Velupandian, Rockesh Gurtu, Dorothy Trump, William Newman, Tao Wang, Charles McCollum. (2010) Genetics of patent foramen ovale—NKX2-5 and beyond. Clinical Neurology and Neurosurgery 112:6, 457-458
CrossRef46
M. Pepi, A. Evangelista, P. Nihoyannopoulos, F. A. Flachskampf, G. Athanassopoulos, P. Colonna, G. Habib, E. B. Ringelstein, R. Sicari, J. L. Zamorano, , , M. Sitges, P. Caso. (2010) Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). European Journal of Echocardiography 11:6, 461-476
CrossRef47
M. R. Di Tullio. (2010) Patent foramen ovale and risk of stroke: is there more that we should know?. European Journal of Neurologyno-no
CrossRef48
Karin M. Henriksson, Bahman Farahmand, Saga Johansson, Signild Åsberg, Andreas Terént, Nils Edvardsson. (2010) Survival after stroke — The impact of CHADS2 score and atrial fibrillation. International Journal of Cardiology 141:1, 18-23
CrossRef49
Anastassios I. Mylonas, Christos A. Skouteris, Georgios Vretakos, Calliope Petraki. (2010) Cryptogenic Stroke and Parotid Tumor Surgery: A Case Report. Journal of Oral and Maxillofacial Surgery 68:5, 1205-1208
CrossRef50
R. Feurer, S. Sadikovic, D. Sepp, L. Esposito, M. Schleef, A. Bockelbrink, J. Schwarze, B. Hemmer, D. Sander, H. Poppert. (2010) Patent foramen ovale is not associated with an increased risk of stroke recurrence. European Journal of Neurology
CrossRef51
U. Laufs, U.C. Hoppe, S. Rosenkranz, P. Kirchhof, M. Böhm, H.-C. Diener, M. Endres, M. Grond, W. Hacke, T. Meinertz, E.B. Ringelstein, J. Röther, M. Dichgans. (2010) Kardiologische Diagnostik nach zerebraler Ischämie. Der Nervenarzt 81:4, 444-462
CrossRef52
HoHai Van, Paul Poommipanit, Mostafa Shalaby, Rubine Gevorgyan, Chi-Hong Tseng, Jonathan Tobis. (2010) Sensitivity of Transcranial Doppler Versus Intracardiac Echocardiography in the Detection of Right-to-Left Shunt. JACC: Cardiovascular Imaging 3:4, 343-348
CrossRef53
Dolores Mesa, Martín Ruiz, Mónica Delgado, José Suárez de Lezo, Manuel Pan, Ignacio Tejero, Daniel García, Manuel Crespín, Carmen León, Francisco Toledano, Francisco Mazuelos, Juan J. Ochoa, Enrique Bescansa. (2010) Prevalencia de foramen oval permeable diagnosticado mediante ecocardiografía transesofágica en pacientes de edad igual o mayor que 55 años con ictus criptogénico. ¿Es diferente que en pacientes jóvenes?. Revista Española de Cardiología 63:3, 315-322
CrossRef54
L. H. Bonati, S. G. Wetzel, A. Kessel-Schaefer, P. Buser, P. A. Lyrer, S. T. Engelter. (2010) Diffusion-weighted imaging findings differ between stroke attributable to spontaneous cervical artery dissection and patent foramen ovale. European Journal of Neurology 17:2, 307-313
CrossRef55
Monica Angelini, Giorgio Lambru, Sara Montepietra, Massimo Riccardi, Carla Zanferrari, Ermelinda Bortone. (2010) Unexplained dyspnea in an old patient with recurrent stroke: platypnea–orthodeoxia syndrome and evidence of patent foramen ovale. Neurological Sciences 31:1, 93-94
CrossRef56
Marco R. Di Tullio. (2010) Patent Foramen Ovale: Echocardiographic Detection and Clinical Relevance in Stroke. Journal of the American Society of Echocardiography 23:2, 144-155
CrossRef57
David E Thaler, David M Kent. (2010) Rethinking trial strategies for stroke and patent foramen ovale. Current Opinion in Neurology 23:1, 73-78
CrossRef58
2010. Synopsis of Adult Cardiac Surgical Disease. , 1-83.
CrossRef59
Sargis Khoobiar, Aaron VanHise, Renato Apolito, Marc Cohen. (2010) Interatrial thrombus-in-transit resulting in paradoxical thromboembolism. Journal of Thrombosis and Thrombolysis 29:1, 127-129
CrossRef60
Kazumi Kimura. (2010) Clinical characteristics and diagnosis of TIA. Nosotchu 32:6, 719-724
CrossRef61
U.C. Hoppe. (2009) Kardiologische Diagnostik nach Schlaganfall. Der Internist 50:11, 1210-1217
CrossRef62
Rajeev Garg, Azam Khaja, Richard Madsen, Martin A. Alpert, Lokesh Tejwani, Kul Aggarwal. (2009) Observer Variation in the Echocardiographic Measurement of Maximum Atrial Septal Excursion: A Comparison of M-Mode with Two-Dimensional or Transesophageal Echocardiography. Echocardiography 26:10, 1122-1126
CrossRef63
Christian Spies, Melvin Wong. (2009) Patent foramen ovale and cryptogenic stroke: a complex neuro–cardio–vascular problem. Expert Review of Cardiovascular Therapy 7:11, 1455-1467
CrossRef64
David R. Holmes, Howard A. Cohen, Carlos Ruiz. (2009) Patent Foramen Ovale, Systemic Embolization, and Closure. Current Problems in Cardiology 34:10, 483-530
CrossRef65
Marco R Di Tullio, Shunichi Homma. (2009) Patent foramen ovale and stroke: what should be done?. Current Opinion in Hematology 16:5, 391-396
CrossRef66
Ignacio Cruz-González, Jorge Solis, Thomas J Kiernan, Bryan P Yan, Yat-Yin Lam, Igor F Palacios. (2009) Clinical manifestation and current management of patent foramen ovale. Expert Review of Cardiovascular Therapy 7:8, 1011-1022
CrossRef67
Jill T. Jesurum, Cindy J. Fuller, Mark A. Moehring, Joshua Renz, Meryl Harley, Merrill P. Spencer. (2009) Unilateral versus Bilateral Middle Cerebral Artery Detection of Right-to-Left Shunt by Power M-Mode Transcranial Doppler. Journal of Neuroimaging 19:3, 235-241
CrossRef68
Zisis Gatzioufas, Matthias Krause, Ursula Löw, Berthold Seitz. (2009) Bilateral macular hole in a patient with chronic renal failure after recurrent deep vein thrombosis. Graefe's Archive for Clinical and Experimental Ophthalmology 247:7, 1003-1005
CrossRef69
Magnus C. Johansson, Peter Eriksson, Mikael Dellborg. (2009) The significance of patent foramen ovale. International Journal of Cardiology 134:1, 17-24
CrossRef70
L. Caputi, Domenico D’Amico, S. Usai, L. Grazzi, E. A. Parati, G. Bussone. (2009) Prevalence and characteristics of right-to-left shunt in migraine with aura: a survey on 120 Italian patients. Neurological Sciences 30:S1, 109-111
CrossRef71
Monique A. Ford, Guy S. Reeder, Ryan J. Lennon, Robert D. Brown, George W. Petty, Allison K. Cabalka, Frank Cetta, Donald J. Hagler. (2009) Percutaneous Device Closure of Patent Foramen Ovale in Patients With Presumed Cryptogenic Stroke or Transient Ischemic Attack. JACC: Cardiovascular Interventions 2:5, 404-411
CrossRef72
Edward Haosheng Yu, Codrin Lungu, Ronald M. Kanner, Richard Benjamin Libman. (2009) The Use of Diagnostic Tests in Patients with Acute Ischemic Stroke. Journal of Stroke and Cerebrovascular Diseases 18:3, 178-184
CrossRef73
Jian-Ren Liu, Björn-Moritz Plötz, Axel Rohr, Robert Stingele, Olav Jansen, Karsten Alfke. (2009) Association of right-to-left shunt with frontal white matter lesions in T2-weighted MR imaging of stroke patients. Neuroradiology 51:5, 299-304
CrossRef74
Patrick T. O'Gara, Steven R. Messe, E. Murat Tuzcu, Gloria Catha, John C. Ring. (2009) Percutaneous Device Closure of Patent Foramen Ovale for Secondary Stroke Prevention. Journal of the American College of Cardiology 53:21, 2014-2018
CrossRef75
Mark Reisman. (2009) Patent Foramen Ovale: Closing Arguments
Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology. Dr. Reisman is on the advisory boards of Coaptus Inc. and Ovalis Inc., and has received research grants from NMT Inc. and Coherex Medical Inc.. JACC: Cardiovascular Interventions 2:5, 412-414
CrossRef76
Andreas Wahl, Tony Tai, Fabien Praz, Markus Schwerzmann, Christian Seiler, Krassen Nedeltchev, Stephan Windecker, Heinrich P. Mattle, Bernhard Meier. (2009) Late Results After Percutaneous Closure of Patent Foramen Ovale for Secondary Prevention of Paradoxical Embolism Using the Amplatzer PFO Occluder Without Intraprocedural Echocardiography. JACC: Cardiovascular Interventions 2:2, 116-123
CrossRef77
Eduardo Pinar, Agustín Albarrán, José A. Baz, Josepa Mauri. (2009) Actualización en cardiología intervencionista. Revista Española de Cardiología 62, 101-116
CrossRef78
F. Krizanic, M. Sigler, H. R. Figulla. (2009) Transvenous Closure of Patent Foramen Ovale: Preliminary Results with a New Self-Expanding Nitinol Wire Mesh in a Swine Model. Cardiology Research and Practice 2009, 1-4
CrossRef79
Christian Spies, Abha Khandelwal, Ines Timmemanns, Clifford J. Kavinsky, Rainer Schräder, Ziyad M. Hijazi. (2008) Recurrent events following patent foramen ovale closure in patients above 55 years of age with presumed paradoxical embolism. Catheterization and Cardiovascular Interventions 72:7, 966-970
CrossRef80
Mark D. Osten, Eric M. Horlick. (2008) The ultimate proof of paradoxical embolism and a percutaneous solution. Catheterization and Cardiovascular Interventions 72:6, 837-840
CrossRef81
David E Thaler, Jeffrey L Saver. (2008) Cryptogenic stroke and patent foramen ovale. Current Opinion in Cardiology 23:6, 537-544
CrossRef82
E.T.D. Hoey, H. Mansoubi, D. Gopalan, C.K. Choong, A.D. Tasker. (2008) Pulmonary thromboembolism with thrombus trapped in a patent foramen ovale — the “floating thrombus sign” on CTPA. Clinical Radiology 63:11, 1280-1284
CrossRef83
Jorge R. Kizer. (2008) Evaluation of the patient with unexplained stroke. Coronary Artery Disease 19:7, 535-540
CrossRef84
William D. Freeman, Maria I. Aguilar. (2008) Stroke Prevention in Atrial Fibrillation and Other Major Cardiac Sources of Embolism. Neurologic Clinics 26:4, 1129-1160
CrossRef85
Fabienne Perren, Elena Savva, Theodor Landis. (2008) Transforaminal Doppler: An alternative to transtemporal approach for right-to-left cardiac shunt assessment. Journal of the Neurological Sciences 273:1-2, 49-50
CrossRef86
P.D. Schellinger, P. Ringleb, W. Hacke. (2008) Leitlinien zum Management von Patienten mit akutem Hirninfarkt oder TIA der Europäischen Schlaganfallorganisation 2008. Der Nervenarzt 79:10, 1180-1202
CrossRef87
J. Benbassat, R. Baumal. (2008) Variability in duration of follow up may bias the conclusions of cohort studies of patients with patent foramen ovale. European Journal of Neurology 15:9, 909-915
CrossRef88
Simona Velicu, José Biller, Lotfi Hacein-Bey, Jeffrey H. Freihage, Fred Leya. (2008) Paradoxical Embolism to the Central Nervous System After Sexual Intercourse in a Young Woman with a Complex Atrial Septal Abnormality. Journal of Stroke and Cerebrovascular Diseases 17:5, 320-324
CrossRef89
M. Force, P. Massabuau, V. Larrue. (2008) Prevalence of atrial septal abnormalities in older patients with cryptogenic ischemic stroke or transient ischemic attack. Clinical Neurology and Neurosurgery 110:8, 779-783
CrossRef90
Ignacio Cruz-González, Jorge Solis, Ignacio Inglessis-Azuaje, Igor F. Palacios. (2008) Foramen oval permeable: situación actual. Revista Española de Cardiología 61:7, 738-751
CrossRef91
Isabel Reiffenstein, Nicolas Majunke, Nina Wunderlich, Phillip Carter, Randall Jones, Horst Sievert. (2008) Percutaneous closure of patent foramen ovale with a novel FlatStent™. Expert Review of Medical Devices 5:4, 419-425
CrossRef92
Simon R. Dixon, Cindy L. Grines, William W. O'Neill. (2008) The Year in Interventional Cardiology. Journal of the American College of Cardiology 51:24, 2355-2369
CrossRef93
Domenico D’Amico, Susanna Usai, Luigi Caputi, Gennaro Bussone. (2008) Does closure of a patent foramen ovale have a role in the treatment of migraine with aura?. Neurological Sciences 29:S1, 23-27
CrossRef94
Gianfranco Butera, Enrico Romagnoli, Giuseppe Sangiorgi, Luigi Caputi, Massimo Chessa, Mario Carminati. (2008) Patent foramen ovale percutaneous closure: the no-implant approach. Expert Review of Medical Devices 5:3, 317-321
CrossRef95
(2008) Patent Foramen Ovale and Cryptogenic Stroke. New England Journal of Medicine 358:14, 1518-1521
Full Text96
Bernhard Meier. (2008) Association between venous and arterial thrombosis. The Lancet 371:9615, 809
CrossRef97
(2008) Association between patent foramen ovale and cryptogenic stroke in older individuals. Nature Clinical Practice Cardiovascular Medicine 5:3, 124-125
CrossRef98
Kook-Jin Chun. (2008) Patent Foramen Ovale and Cryptogenic Stroke. Korean Circulation Journal 38:12, 631
CrossRef99
(2008) Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008. Cerebrovascular Diseases 25:5, 457-507
CrossRef100
M. Zuber, F. Cuculi, E. Oechslin, P. Erne, R. Jenni. (2008) Is transesophageal echocardiography still necessary to exclude patent foramen ovale?. Scandinavian Cardiovascular Journal 42:3, 222-225
CrossRef101
Dawn Fallik. (2008) Higher Prevalence of Patent Foramen Ovale Reported in Cryptogenic Stroke. Neurology Today 8:2, 1,12
CrossRef102
S. Reverté Villarroya. (2008) Detección shunt derecha-izquierda en pacientes con ictus isquémico: Colaboración de enfermería en la técnica de detección. Revista Científica de la Sociedad Española de Enfermería Neurológica 2008:27, 27-30
CrossRef
- Letters
