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Does Patent Foramen Ovale Promote Cryptogenic Stroke?
Question: I am a 42 year old female, previously healthy and 19 months postpartum. I had a cryptogenic stroke on feb 22, a pfo was found on tee, and I had a pfo closure via catheter with gore helex device on May 28. Two weeks later (after returning to work), I began having lots of afib and flutter. Your thoughts? Could this be temporary and stress related? Or is it reasonable to revise the theory of the stroke and keep me on coumadin for life? Dr. C. (Phd, not MD)
Brief Answer:
Continue anticoagulation at present
Detailed Answer:
Hello XXXX,
I have gone through your question and understand your concerns.
Analysing all your history and clinical profile I have some suggestions.
1) May be your cryptogenic stroke was not due to PFO and some other cause of young stroke to be evaluated properly like hypercoagulation states, hyperhomocystenemia or other causes.
2) Some studies have shown no need for anticoagulation in patients with PFO closure with no other associated complications.
3) In your case as you are having atrial fibrillation and flutter post procedure you have to take anticoagulation at present for some duration. Stopping of drug at this juncture is not safe and no clear guidelines for probable duration.
I will advise you to be in touch with your treating doctor and discuss about the need for continuation of anticoagulation after all other evaluation at a later date when all is controlled.
Hope you found the answer helpful.
Do get back for further queries
Regards
DR Neeraj Kumar
Continue anticoagulation at present
Detailed Answer:
Hello XXXX,
I have gone through your question and understand your concerns.
Analysing all your history and clinical profile I have some suggestions.
1) May be your cryptogenic stroke was not due to PFO and some other cause of young stroke to be evaluated properly like hypercoagulation states, hyperhomocystenemia or other causes.
2) Some studies have shown no need for anticoagulation in patients with PFO closure with no other associated complications.
3) In your case as you are having atrial fibrillation and flutter post procedure you have to take anticoagulation at present for some duration. Stopping of drug at this juncture is not safe and no clear guidelines for probable duration.
I will advise you to be in touch with your treating doctor and discuss about the need for continuation of anticoagulation after all other evaluation at a later date when all is controlled.
Hope you found the answer helpful.
Do get back for further queries
Regards
DR Neeraj Kumar
Above answer was peer-reviewed by :
Dr. Yogesh D
Thank you for your reply Dr. XXXXXXX
Hypercoagulation states were ruled-out during my hospital stay in February. I can upload the lab report if you'd like to see it.
I do realize that I am stuck with coumadin for at least six months now, and may even need to continue (either coumadin, or something milder like plavix) for maybe a year. I am prepared to cope with that. I am of course in ongoing consultation with my team of physicians, and my internist is keeping a close eye on everything (luckily her office is across the hall from mine and I speak with her weekly now).
However, my main concern at this point is that my regular cardiologist has revised the theory of the stroke for reasons that neither I, or my internist, understand clearly. The original theory was that perhaps the enlarged pelvic vessels from the pregnancy could have encouraged clot formation, which then traveled to the heart, escaped through the PFO, split into 3, causing the 3 lesions seen on MRI.
Now, my cardiologist thinks that perhaps I had previous undetected afib that was the true cause of the stroke. This seems odd to me (and to my internist) because: 1) I have never experienced this type of chest sensations (strong palpitations), 2) the one time I ever experienced mild palpitations was in the first trimester of pregnancy, and my cardiologist did an EKG, blood work, and echo of the heart, and a 24-hour holter monitor and concluded that everything was normal, 3) during the 4-day hospitalization for stroke, I had another heart echo and 4 days of telemetry. No one mentioned ever the possibility of pre-existing afib. But now my cardiologist is saying that I seem to have "afib tracks" that are likely genetic. What are those?
Let me know any records you'd like to see and I can upload them.
Hypercoagulation states were ruled-out during my hospital stay in February. I can upload the lab report if you'd like to see it.
I do realize that I am stuck with coumadin for at least six months now, and may even need to continue (either coumadin, or something milder like plavix) for maybe a year. I am prepared to cope with that. I am of course in ongoing consultation with my team of physicians, and my internist is keeping a close eye on everything (luckily her office is across the hall from mine and I speak with her weekly now).
However, my main concern at this point is that my regular cardiologist has revised the theory of the stroke for reasons that neither I, or my internist, understand clearly. The original theory was that perhaps the enlarged pelvic vessels from the pregnancy could have encouraged clot formation, which then traveled to the heart, escaped through the PFO, split into 3, causing the 3 lesions seen on MRI.
Now, my cardiologist thinks that perhaps I had previous undetected afib that was the true cause of the stroke. This seems odd to me (and to my internist) because: 1) I have never experienced this type of chest sensations (strong palpitations), 2) the one time I ever experienced mild palpitations was in the first trimester of pregnancy, and my cardiologist did an EKG, blood work, and echo of the heart, and a 24-hour holter monitor and concluded that everything was normal, 3) during the 4-day hospitalization for stroke, I had another heart echo and 4 days of telemetry. No one mentioned ever the possibility of pre-existing afib. But now my cardiologist is saying that I seem to have "afib tracks" that are likely genetic. What are those?
Let me know any records you'd like to see and I can upload them.
Brief Answer:
Yes atrial fibrillation may be the cause
Detailed Answer:
Hello dear,
I have gone through your question and understand your concerns.
Atrial fibrillation tracts are pathways connecting atrium to ventricle and have genetic basis also.
To evaluate regarding this possibility you have to consult some arrhythmia expert cardiologist who can diagnose such an entity and treat accordingly.
It's difficult to definitely tell about the cause of stroke in your case and all possibilities discussed may be culprit.
Cardiac origin due to AF should be considered greater possibility than paradoxical emboli.
You need to take anticoagulants for few months atleast.
you can upload your previous reports for evaluation to me.
Hope you found the answer helpful.
Regards
Dr Neeraj Kumar
Neurologist
Yes atrial fibrillation may be the cause
Detailed Answer:
Hello dear,
I have gone through your question and understand your concerns.
Atrial fibrillation tracts are pathways connecting atrium to ventricle and have genetic basis also.
To evaluate regarding this possibility you have to consult some arrhythmia expert cardiologist who can diagnose such an entity and treat accordingly.
It's difficult to definitely tell about the cause of stroke in your case and all possibilities discussed may be culprit.
Cardiac origin due to AF should be considered greater possibility than paradoxical emboli.
You need to take anticoagulants for few months atleast.
you can upload your previous reports for evaluation to me.
Hope you found the answer helpful.
Regards
Dr Neeraj Kumar
Neurologist
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Ahh, thank you Dr. XXXXXXX I think I'm finally understanding more everything that is going on with me. I believe my neurologist said that I had an "embolic event" (which would explain the recommendation to close PFO, correct?), but please tell me what question(s) I need to ask her at my next visit to help us better assess the true cause (or most likely cause) of the stroke?
Which reports specifically would you like to see? I have all my hospitalization records from the stoke, and my recent holter monitor.
If I understand you correctly, a cardiac electrophysiologist would evaluate for presence of afib tracks? Is this something that can be diagnosed for sure, or is this something that the electrophysiologist would give his best educated guess, looking at the holter results and my history?
Which reports specifically would you like to see? I have all my hospitalization records from the stoke, and my recent holter monitor.
If I understand you correctly, a cardiac electrophysiologist would evaluate for presence of afib tracks? Is this something that can be diagnosed for sure, or is this something that the electrophysiologist would give his best educated guess, looking at the holter results and my history?
Brief Answer:
Consult electrophysiology expert
Detailed Answer:
Hello XXXX,
You need to discuss about atrial fibrillation as a cause for stroke with your neurologist. The three discrete location of stroke in a vascular territory is a suggestion of some embolisation.
You can also take an appointment with electrophysiology experts as they are well trained for diagnosis and treatment of aberrant or accessory connections between atria and ventricle.
You can upload your mri images/report and coagulation profile( Protein C, Protein S, antithrombin III, factor V mutation, PT/INR).
I will be happy to help.
Rehards
DR XXXXXXX XXXXXXX
neurologist
Consult electrophysiology expert
Detailed Answer:
Hello XXXX,
You need to discuss about atrial fibrillation as a cause for stroke with your neurologist. The three discrete location of stroke in a vascular territory is a suggestion of some embolisation.
You can also take an appointment with electrophysiology experts as they are well trained for diagnosis and treatment of aberrant or accessory connections between atria and ventricle.
You can upload your mri images/report and coagulation profile( Protein C, Protein S, antithrombin III, factor V mutation, PT/INR).
I will be happy to help.
Rehards
DR XXXXXXX XXXXXXX
neurologist
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Above answer was peer-reviewed by :
Dr. Prasad
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