Koutroulou Ioanna, Tsivgoulis Georgios, Tsalikakis Dimitrios, Karacostas Dimitris, Grigoriadis Nikolaos, Karapanayiotides Theodoros
Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece.
Front Neurol. 2020 Apr 28;11:281. doi: 10.3389/fneur.2020.00281. eCollection 2020.
Percutaneous closure of patent foramen ovale (PFO) in selected patients with cryptogenic cerebrovascular ischemic events (CEs) decreases the risk of recurrent stroke; however, optimal patient selection criteria are still under investigation. Candidates for PFO closure are usually selected from the pool of CE patients with a high risk of Paradoxical Embolism (RoPE) score. The RoPE score calculates the probability that PFO is causally related to stroke, based on PFO prevalence in patients with CE compared with that in healthy subjects. The latter has been set at 25% based on the average of autopsy and transesophageal echocardiography (TEE) studies. We conducted a comprehensive review of studies investigating PFO prevalence in general population and in patients with CE and non-CE using autopsy, TEE, transcranial Doppler (TCD) or transthoracic echocardiography (TTE). Studies were excluded if they (1) reported data from referred subjects with underlying cerebrovascular disease or (2) did not specify etiologically the events. In healthy/control subjects, PFO prevalence was 24.2% (1,872/7,747) in autopsy studies, 23.7% (325/1,369) in TEE, 31.3% (111/355) in TCD, and 14.7% (186/1,267) in TTE studies. All diagnostic modalities included PFO prevalence was higher in CE compared with healthy/control population [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 2.5-3.8] and compared with non-CE (OR = 2.3, 95% CI = 2.0-2.6). In patients with CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (48.9 vs. 27.3%, < 0.0001, OR = 2.6 with 95% CI = 2.0-3.3) or TCD (58.1 vs. 41%, OR = 1.9, 95% CI = 1.6-2.5), but not TTE (53.3 vs. 37.5%, = 0.16). Regarding non-CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (20 vs. 12.9%, OR = 1.7, 95% CI = 1.0-2.8) but not TTE (10.4 vs. 7.8%, = 0.75) or TCD (22.8 vs. 20.1%, = 0.56). Given the limitations of autopsy and TEE studies, there is good reason not to take a fixed 25% PFO prevalence for granted. The estimation of degree of causality may be underestimated or overestimated in populations with PFO prevalence significantly lower or higher than the established. Given the high sensitivity, non-invasive nature, low cost, and repeatability of TCD, future large-scale TCD-based studies should investigate potential heterogeneity in PFO prevalence in different healthy racial/ethnic populations.
在部分患有不明原因脑血管缺血事件（CEs）的患者中，经皮闭合卵圆孔未闭（PFO）可降低复发性中风的风险；然而，最佳的患者选择标准仍在研究中。PFO闭合的候选者通常从具有高反常栓塞风险（RoPE）评分的CE患者群体中选择。RoPE评分基于CE患者与健康受试者中PFO的患病率，计算PFO与中风存在因果关系的概率。根据尸检和经食管超声心动图（TEE）研究的平均值，后者被设定为25%。我们对使用尸检、TEE、经颅多普勒（TCD）或经胸超声心动图（TTE）调查普通人群以及CE和非CE患者中PFO患病率的研究进行了全面综述。如果研究（1）报告了患有潜在脑血管疾病的转诊受试者的数据，或（2）未从病因学上明确事件，则将其排除。在健康/对照受试者中，尸检研究中PFO患病率为24.2%（1872/7747），TEE中为23.7%（325/1369），TCD中为31.3%（111/355），TTE研究中为14.7%（186/1267）。所有诊断方法显示，与健康/对照人群相比，CE患者中PFO患病率更高[优势比（OR）=3.1，95%置信区间（CI）=2.5 - 3.8]，与非CE患者相比也更高（OR = 2.3，95%CI = 2.0 - 2.6）。在CE患者中，当诊断方法为TEE（48.9%对27.3%，<0.0001，OR = 2.6，95%CI = 2.0 - 3.3）或TCD（58.1%对41%，OR = 1.9，95%CI = 1.6 - 2.5）时，年轻人的PFO患病率高于老年人，但TTE（53.3%对37.5%，=0.16）时并非如此。对于非CE患者，当诊断方法为TEE（20%对12.9%，OR = 1.7，95%CI = 1.0 - 2.8）时，年轻人的PFO患病率高于老年人，但TTE（10.4%对7.8%，=0.75）或TCD（22.8%对20.1%，=0.56）时并非如此。鉴于尸检和TEE研究的局限性，没有充分理由将固定的25%的PFO患病率视为理所当然。在PFO患病率显著低于或高于既定值的人群中，因果关系程度的估计可能被低估或高估。鉴于TCD具有高敏感性、非侵入性、低成本和可重复性，未来基于TCD的大规模研究应调查不同健康种族/族裔人群中PFO患病率的潜在异质性。
