Spontaneous large right-to-left shunt and migraine headache with aura are risk factors for recurrent stroke in patients with a patent foramen ovale

Background We sought to determine whether migraine headache with aura (MHA) and spontaneous large right-to-left (R–L) shunt are risk factors for recurrent cerebral ischemic events in cryptogenic stroke patients with a patent foramen ovale (PFO). Methods 140 patients with a PFO and cryptogenic stroke underwent transcatheter defect closure at our institution at a mean age of 45 ± 13 years. We retrospectively analyzed follow-up data from the first cerebral ischemic event to the time of PFO closure. Before the procedure, all patients underwent transesophageal echocardiography (TEE); Transcranial Doppler scanning (TCD) was additionally performed on the last 59 patients. We analyzed the impact of MHA, thrombophilia, spontaneous large R–L shunt, and atrial septal aneurysm (ASA) on the risk of recurrent cerebral ischemic events. Results 44 patients (31%) had had at least 1 recurrent event during a follow-up of 2.2 ± 2.6 years. Patients with recurrent events were more commonly females (p = 0.0001), had more often an associated thrombophilia (p = 0.0077), and had a higher prevalence of spontaneously large R–L shunt both at TEE and at TCD (p < 0.05). They also had more commonly a history of MHA (p = 0.0009) and more frequent episodes of MHA (p = 0.0048). Patients with MHA had a higher risk of recurrent events when compared to patients without (odds ratio 3.87, 95% CI 1.75 to 8.50). Thrombophilia (p = 0.001) and spontaneous large R–L shunt (p = 0.02) were independent predictors of recurrent stroke. Conclusions In cryptogenic stroke patients with a PFO, a history of MHA, large spontaneous large R–L shunt, and thrombophilia are all associated with a higher risk of recurrent events.