Strokes in children associated with patent foramen ovale: diagnostic method and secondary prevention

Authors: Kurako M.M.¹, Pursanov M.G.¹, Abramyan M.A.¹ ², Bedin A.V.¹, Shchederkina I.O.¹

Company: ¹ Morozov Children’s City Clinical Hospital, Moscow, Russian Federation
² Patrice Lumumba Peoples’ Frendship University of Russia, Moscow, Russian Federation

Cite as: Kurako M.M., Pursanov M.G., Abramyan M.A., Bedin A.V., Shchederkina I.O. Strokes in children associated with patent foramen oval: diagnostic method and secondary prevention. Children’s Heart and Vascular Diseases. 2023; 20 (4): 242–253 (in Russ.). DOI: 10.24022/1810-0686-2023-20-4-242-253

Received / Accepted: 13.10.2023 / 11.12.2023

Keywords: stroke in children PFO-associated stroke right-left shunt contrast echocardiography cryptogenic arterial ischemic stroke occluder acute celebrovascular accident

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Abstract

Objective. The aim of the study was to identify possible paradoxal embolism (PE) using contrast transthoracic echocardiography (TTE) with a functional test to identify the patent foramen ovale (PFO) associated strokes in children for further endovascular prevention of cryptogenic arterial ishemic stroke (CAIS) and transient ishemic attack (TIA).

Material and methods. In the period from January 2019 to December 2023, 31 children diagnosed with CAIS and TIA were searched for a right-to-left shunt (RLS) using TTE with a bubble test with a mandatory component of the study – performing a test – Valsalva maneuver. The assessment of the probability of PE and the assessment of the clinical significance of PFO was carried out in accordance with the PASCAL classification and the Risk of Paradoxical Embolism Score (RoPE) scale.

Results. TTE revealed PFO in 15 (48.4%) out of 31 children with a diameter of Мe (Q1 –Q3 ) 2.5 (2.5–4.0) mm. Atrial septal aneurysm (ASA) was detected in 4 children, ASA was combined with PFO in 3 children. In cTTE, a RLS was found in 18 patients: in 15 of them, TTE confirmed the presence of PFO, while in 3 PFO it was not identified. A small shunt was detected in 4 (22.2%) patients, a medium shunt in 3 (11.1%) and a large shunt in 11 (66.7%). In 13 patients, shunting through the interatrial septum was not detected. All 31 patients were at high risk of developing PE according to RoPEs scale – 9 or more points. In accordance with the PASCAL classification, in 68.4% of patients, PFO can be considered as a probable cause of СAIS, in 31.6% of patients, the role of PFO in the development of stroke was possible. In 10 (38.4%) patients with CIS and in 2 (40%) children with TIA with large RLS and a probable cause of PFO-associated stroke according to the PASCAL classification, an intercollegiate decision was made to perform transcatheter closure of the PFO. In 100% of cases, hermetic closure of the PFO was determined by the absence of blood discharges on the interatrial septum.

Conclusions. All children who have undergone cryptogenic stroke and/or TIA of unknown etiology require cTTE to determine possible PE through PFO with further optimization of secondary prevention of CIS and TIA. Endovascular closure of PFO is an effective and safe method of secondary prevention of embolic cryptogenic strokes in children.

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About the authors

Mariya M. Kurako, Cand. Med. Sci., Functional Diagnostics Doctor, Ultrasonic Diagnostician; ORCID
Manolis G. Pursanov, Dr. Med. Sci., Endovascular Surgeon; ORCID
Mikhail A. Abramyan, Dr. Med. Sci., Professor of Chair of Pediatrics, Head of Department of Emergency Cardiac Surgery and Interventional Cardiology; ORCID
Aleksey V. Bedin, Cardiovascular Surgeon; ORCID
Inna O. Shchederkina, Cand. Med. Sci., Head of Center for the Treatment of Cerebrovascular Pathology in Children and Adolescents (Children’s Stroke Center), Neurologist, Epileptologist; ORCID

Chief Editor

Konstantin V. Shatalov
MD, PhD, DSc, Professor
Bakoulev National Medical Research Center for Cardiovascular Surgery

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