REPLY
Searching for Patent Foramen Ovale in Patients with Stroke
Shunichi Homma;
Marco DiTullo; and
Ralph Sacco
15 April 1993 | Volume 118 Issue 8 | Page 648
IN RESPONSE:
Other factors potentially associated with a cryptogenic stroke include intracardiac mass or thrombus [1] and aortic arch mass [2]. Pulmonary venous thrombi, described by Remenchik and colleagues [3], and peripheral embolization was not seen in our cohort but was mentioned in our article [4] as an infrequent cause of cerebral embolization. In-vivo diagnosis, however, is difficult. Thrombi located close to the left atrium in major pulmonary veins may be detected by transesophageal echocardiography.
The epidemiologic evidence of a relation between patent foramen ovale and ischemic stroke has been established by us [4] and by others [5]. However, as Dr. Layne indicates, a cause-effect relation between patent foramen ovale and stroke has not been established in a single patient, partly because of limited knowledge of associated factors, such as the role of coexisting deep venous thrombosis or hypercoagulable states. We agree with Dr. Layne that contrast echocardiography and transesophageal echocardiography in all patients with cryptogenic stroke may not be cost-effective because of the lack of available therapy. They represent, however, the first necessary steps in obtaining further knowledge of the natural history of stroke in association with patent foramen ovale and of the effect of therapeutic interventions (anticoagulation, antiplatelet agents, or closure) on the stroke recurrence rate.
1. Cujec B, Polasek P, Voll C, Squaib A. Transesophageal echocardiography in the detection of potential cardiac source of embolism in stroke patients. Stroke. 1991; 22:727-33.
2. Amarenco P, Cohen A, Baudrimont M, Bousser MG. Transesophageal echocardiographic detection of aortic arch disease in patients with cerebral infarction. Stroke. 1992; 23:1005-9.
3. Remenchik AP, Sufian DP, Dhekne RR. Nonparadoxical systemic artery embolus. Tex Med. 1987; 83:53-4.
4. 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; 117:461-5.
5. Lechat P, Mas JL, Lascault G, Loron P, Theard M, Kilmeczac M, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med. 1988; 318:1148-52.
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