What is the management plan for a patient with a history of cerebrovascular accident due to embolism, patent foramen ovale, labile hypertension, migraines with aura, and cervical spinal stenosis?

Management of Patient with Cerebrovascular Accident due to PFO and Multiple Comorbidities

For a patient with history of cerebrovascular accident due to embolism of precerebral artery with patent foramen ovale, PFO closure plus antiplatelet therapy is strongly recommended over antiplatelet therapy alone to prevent recurrent stroke. 1, 2

Assessment of Stroke Etiology and PFO Causality

1. Confirm cryptogenic stroke diagnosis:

   • Rule out other stroke etiologies (atrial fibrillation, carotid disease, etc.)
   • Verify embolic pattern on imaging (cortical infarct rather than lacunar)
   • Assess for high-risk PFO features:
     • Atrial septal aneurysm
     • Large interatrial shunt
     • Substantial right-to-left shunt 2

2. Apply risk stratification tools:

   • Risk of Paradoxical Embolism (RoPE) score to determine likelihood that PFO caused the stroke
   • PFO-Associated Stroke Causal Likelihood (PASCAL) classification 3
   • Higher scores indicate greater likelihood that PFO was the stroke cause

Treatment Recommendations

Primary Recommendation

• PFO closure plus antiplatelet therapy is strongly recommended for this patient 1, 2
• Benefits:
  • 8.7% absolute risk reduction in recurrent ischemic stroke over 5 years (NNT = 12) 1
  • Annualized stroke incidence of 0.47% with PFO closure vs 1.09% with medical therapy alone 3

Antiplatelet vs Anticoagulation

• If PFO closure is performed:
  • Continue single antiplatelet therapy (typically aspirin 81mg daily) long-term 1, 2
• If PFO closure cannot be performed:
  • Anticoagulation is preferred over antiplatelet therapy alone 2
  • For patients with both PFO and venous thromboembolism source, anticoagulation is indicated 1

Management of Comorbidities

1. Labile Hypertension:

   • Optimize blood pressure control (target <130/80 mmHg)
   • Consider ambulatory blood pressure monitoring to assess pattern
   • Select antihypertensive medications that provide consistent 24-hour coverage

2. Migraine with Aura:

   • PFO closure may provide additional benefit for migraine symptoms
   • Continue migraine prophylaxis as needed
   • Avoid vasoconstrictive medications that may increase stroke risk

3. Cervical Spinal Stenosis:

   • Avoid excessive neck manipulation or rotation
   • Consider neurosurgical evaluation if symptoms of myelopathy present
   • Physical therapy with focus on proper body mechanics

4. Weight Loss:

   • Set target BMI <25 kg/m²
   • Dietary counseling and structured exercise program
   • Consider referral to weight management program

Procedural Considerations for PFO Closure

• Procedure details:

  • Minimally invasive catheter-based procedure under local anesthesia
  • Device implanted via femoral vein access
  • Typically requires overnight hospital stay
  • Recovery period of 2-4 weeks 1

• Potential complications:

  • Device or procedure-related adverse events (3.6% absolute risk) 1
  • Persistent atrial fibrillation (1.8% absolute risk increase) 1
  • Transient atrial fibrillation (1.2% absolute risk increase) 1

Follow-up Care

1. Post-PFO closure:

   • Echocardiography at 1 month and 6 months to confirm device position
   • Continue antiplatelet therapy indefinitely
   • Monitor for atrial fibrillation with periodic ECGs

2. If medical therapy only:

   • Regular neurological follow-up
   • Consider long-term cardiac monitoring for occult atrial fibrillation
   • Aggressive vascular risk factor management

Special Considerations

• Paradoxical Embolism Risk: The presence of PFO in this patient with stroke significantly increases risk of death (relative risk 2.4) and recurrent ischemic events 1

• Inferior Vena Cava (IVC) Filter: Consider temporary IVC filter placement before PFO closure if there is evidence of deep vein thrombosis to prevent perioperative paradoxical embolism 1, 4

• Age Considerations: PFO closure shows greatest benefit in patients ≤60 years old; this patient's age should be factored into the decision 2, 3

• Hypercoagulability Assessment: Given the paradoxical embolism, evaluate for underlying hypercoagulable states that may require additional management 5

The evidence strongly supports PFO closure plus antiplatelet therapy for this patient with cerebrovascular accident due to embolism with PFO, as this approach provides the greatest reduction in recurrent stroke risk while managing the patient's multiple comorbidities.