Clinical And Radiographic Analysis Of Patients With Patent Foramen Ovale

Background:Even after extensive studies,one third of stroke patients cannot be determined whose cause is called cryptogenic stroke(cryptogenic stroke,CS).A increasing number of studies have confirmed that patent foramen ovale(patent foramen ovale,PFO)is associated with CS,and the main mechanism of right to left shunt(right-to-left shunt(RLS)and CS is abnormal embolism(paradoxical embolism,PE).The common examination methods for diagnosing PFO mainly include transcranial Doppler sonultrasound(contrast-transcranial Doppler,And c-TCD),transesophageal echocardiogram(transesophageal echocardio-graphy,TEE),transthoracic echocardiography,acoustic contrast(contrastenhanced transthroracic echocardiography,c-TTE),Among them,c-TCD is the preferred method for screening for PFO.The treatment of PFO-related stroke has long been controversial,and studies in recent years show that occlusion is a safe and effective intervention,but large-scale randomized controlled trials are still needed.Objective:To study the clinical and imaging characteristics of PFO related stroke patients,compared the clinical and infarction patterns of CS patients with different PFO size,RLS flow and RLS shunt types,analyzed the correlation between PFO size,RLS flow and RLS shunt types,guide clinicians to make timely and accurate diagnosis and choose the best secondary prevention strategy.Methods:A total of 193 patients with CS and PFO admitted to the Department of Neurology of the Affiliated Hospital of Jining Medical College from June 2019 to May 2022 were included for retrospective analysis.All patients had transthoracic echocardiographic acoustic imaging(c-TTE),transesophageal echocardiography(TEE)and transcranial Doppler sonography(c-TCD),small shunt(n=54),PFO<2mm(n=76)and PFO≥2 mm(n=117),persistent RLS(n=67),and stimulated RLS(n=126).Clinical data and imaging characteristics(number of infarction,site,area,vascularity,vascular involvement)were compared in the three groups,and assessed whether there was a correlation between PFO size,RLS flow and shunt pattern.Results:General data:Among 193 patients,139 patients in the large shunt group,54 patients in the small shunt group,117 patients in the PFO≥2mm group,76 patients in the PFO<2mm group,126 patients in the excitation RLS group and 67 patients in the persistent RLS group.116(60.1%)males and 77(39.9%)females,age range 22 to 55,mean age(45.43±7.54),124(64.2%)patients were younger than 50,69(35.8%)patients were older than 50.Compared with the general data between the small shunt group and the large shunt group,there was a statistical difference in age between the two groups(P<0.05),and there was no statistical difference in gender,smoking history and other risk factors possibly related to cerebrovascular disease between the two groups(P>0.05).The age,gender,smoking history,and other risk factors related to cerebrovascular disease between PFO≥2mm and PFO<2mm and provocation RLS and persistent RLS(P>0.05).Laboratory examination:the Ro PE score was lower than that of the small shunt group,and the difference was statistically significant(P=0.010),without other laboratory indicators and NIHSS scores(P>0.05).There were no significant differences in laboratory indicators and the results of Ro PE and NIHSS scores between the PFO<2mm group and the PFO≥2mm group,and provocation RLS and persistent RLS groups(P>0.05).Imaging data:Of the 193 patients,Single infarction accounted for56.5%,Multiple infarction accounted for 43.5%;Cortical infarcts accounted for 58.0%,Subcortical infarct was 16.1%,Cortical and subcortical infarct occurred in 10.9%,Brain stem infarction accounted for9.8%,Cerebellar infarction 5.2%;Large-area infarction accounted for29.0%,Small-area infarction accounted for 56.5%,Lacunar infarction accounted for 14.5%;Infarct involved the anterior circulation accounted for 50.8%,The posterior circulation accounted for 44.6%,The anterior and posterior circulation involvement accounted for 4.7%;Infarct involvement of the anterior cerebral artery in 2.6%,The middle cerebral artery accounted for 49.2%,The posterior cerebral artery accounted for28.5%,Vertebrobasilar artery in 9.8%),The upper cerebellar artery was1.6%,The anterior inferior cerebellar artery was 1.6%,The posterior inferior cerebellar artery was 2.1%,Middle cerebral and posterior cerebral artery in 3.1%,The cerebral and vertebrobasilar artery was 1.0%,The posterior cerebral and vertebrobasilar artery was present in 0.5%.The rate of small area infarction in a large number of shunt groups was higher than that in the small shunt group,and the difference was statistically significant(P=0.005),while other indicators such as the number of infarcts,infarction site,infarct distribution and vessel of infarction involvement were not different in the two groups(P>0.05).There was no difference in imaging data between the PFO<2mm and PFO≥2mm groups(P>0.05).There were significant differences in the number of infarct,infarct size,and infarction vessels in stimulated RLS and persistent RLS patients(P>0.05),and the incidence of single infarction,large infarction,posterior circulation infarction,and posterior cerebral artery involvement was higher in persistent RLS group,with no difference in infarct site(P>0.05).PFO size,RLS shunt volume and shunt pattern were correlated:The incidence of large shunt in PFO≥2mm group was higher than that in PFO<2mm group,and the difference was statistically significant(x~2=14.835,P<0.001).There was no difference in correlation between PFO diameter and RLS shunt type and RLS shunt quantity and RLS shunt type(P>0.05).Conclusion:1.Patients with PFO related stroke are mainly young and middle-aged men,and have fewer traditional cerebrovascular risk factors.2.The larger the diameter of the foramen ovale,the more the RLS flow.3.The imaging of patients with PFO-related stroke usually showed small-area infarcts in the single cortex,mainly involving the middle cerebral artery.4.The size of foramen ovale does not affect the number,location,area and vascular distribution of infarction;stroke patients with large RLS are more likely to find small infarction on imaging;stroke patients with persistent RLS shunt are more single large infarction,mostly distributed in the posterior circulation,mainly involving the posterior cerebral artery.