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August 23, 2016; 87 (8) Special Article

Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter) [RETIRED]

Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

Steven R. Messé, Gary Gronseth, David M. Kent, Jorge R. Kizer, Shunichi Homma, Lee Rosterman, Scott E. Kasner
First published July 27, 2016, DOI: https://doi.org/10.1212/WNL.0000000000002961
Steven R. Messé
From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.G., L.R.), University of Kansas Medical Center, Kansas City; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Departments of Medicine (Cardiology) and Epidemiology and Population Health (J.R.K.), Albert Einstein College of Medicine, Bronx; and Division of Cardiology (S.H.), Columbia University Medical Center, New York, NY.
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Gary Gronseth
From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.G., L.R.), University of Kansas Medical Center, Kansas City; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Departments of Medicine (Cardiology) and Epidemiology and Population Health (J.R.K.), Albert Einstein College of Medicine, Bronx; and Division of Cardiology (S.H.), Columbia University Medical Center, New York, NY.
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David M. Kent
From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.G., L.R.), University of Kansas Medical Center, Kansas City; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Departments of Medicine (Cardiology) and Epidemiology and Population Health (J.R.K.), Albert Einstein College of Medicine, Bronx; and Division of Cardiology (S.H.), Columbia University Medical Center, New York, NY.
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Jorge R. Kizer
From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.G., L.R.), University of Kansas Medical Center, Kansas City; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Departments of Medicine (Cardiology) and Epidemiology and Population Health (J.R.K.), Albert Einstein College of Medicine, Bronx; and Division of Cardiology (S.H.), Columbia University Medical Center, New York, NY.
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Shunichi Homma
From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.G., L.R.), University of Kansas Medical Center, Kansas City; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Departments of Medicine (Cardiology) and Epidemiology and Population Health (J.R.K.), Albert Einstein College of Medicine, Bronx; and Division of Cardiology (S.H.), Columbia University Medical Center, New York, NY.
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Lee Rosterman
From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.G., L.R.), University of Kansas Medical Center, Kansas City; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Departments of Medicine (Cardiology) and Epidemiology and Population Health (J.R.K.), Albert Einstein College of Medicine, Bronx; and Division of Cardiology (S.H.), Columbia University Medical Center, New York, NY.
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Scott E. Kasner
From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.G., L.R.), University of Kansas Medical Center, Kansas City; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Departments of Medicine (Cardiology) and Epidemiology and Population Health (J.R.K.), Albert Einstein College of Medicine, Bronx; and Division of Cardiology (S.H.), Columbia University Medical Center, New York, NY.
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Citation
Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter) [RETIRED]
Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology
Steven R. Messé, Gary Gronseth, David M. Kent, Jorge R. Kizer, Shunichi Homma, Lee Rosterman, Scott E. Kasner
Neurology Aug 2016, 87 (8) 815-821; DOI: 10.1212/WNL.0000000000002961

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Abstract

Objective: To update the 2004 American Academy of Neurology guideline for patients with stroke and patent foramen ovale (PFO) by addressing whether (1) percutaneous closure of PFO is superior to medical therapy alone and (2) anticoagulation is superior to antiplatelet therapy for the prevention of recurrent stroke.

Methods: Systematic review of the literature and structured formulation of recommendations.

Conclusions: Percutaneous PFO closure with the STARFlex device possibly does not provide a benefit in preventing stroke vs medical therapy alone (risk difference [RD] 0.13%, 95% confidence interval [CI] −2.2% to 2.0%). Percutaneous PFO closure with the AMPLATZER PFO Occluder possibly decreases the risk of recurrent stroke (RD −1.68%, 95% CI −3.18% to −0.19%), possibly increases the risk of new-onset atrial fibrillation (AF) (RD 1.64%, 95% CI 0.07%–3.2%), and is highly likely to be associated with a procedural complication risk of 3.4% (95% CI 2.3%–5%). There is insufficient evidence to determine the efficacy of anticoagulation compared with antiplatelet therapy in preventing recurrent stroke (RD 2%, 95% CI −21% to 25%).

Recommendations: Clinicians should not routinely offer percutaneous PFO closure to patients with cryptogenic ischemic stroke outside of a research setting (Level R). In rare circumstances, such as recurrent strokes despite adequate medical therapy with no other mechanism identified, clinicians may offer the AMPLATZER PFO Occluder if it is available (Level C). In the absence of another indication for anticoagulation, clinicians may routinely offer antiplatelet medications instead of anticoagulation to patients with cryptogenic stroke and PFO (Level C).

This guideline is retired. The recommendations and conclusions are no longer considered valid and no longer supported by the AAN. Retired guidelines should be used for historical reference only. Please see AAN current guidelines here: https://www.aan.com/policy-and-guidelines/guidelines/.

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Approved by the Guideline Development, Dissemination, and Implementation Subcommittee on April 22, 2015; by the Practice Committee on August 25, 2015; and by the AAN Institute Board of Directors on June 2, 2016.

  • Received September 3, 2015.
  • Accepted in final form May 3, 2016.
  • © 2016 American Academy of Neurology

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