The Neurologist as the

Gatekeeper of PFO

Closure in the US: What

is Cryptogenic Stroke and

When Do Neurologists

Think PFO Closure Is

Needed?

David E. Thaler, MD, PhD

Chairman, Department of Neurology

Tufts University School of Medicine

Boston, MA

Disclosure Statement of Financial Interest

• Grant/Research Support

• Consulting Fees/Honoraria

• Major Stock Shareholder/Equity

• Royalty Income

• Ownership/Founder

• Intellectual Property Rights

• Other

• Steering Committee, RESPECT Trial, St Jude Medical

Within the past 12 months, I or my spouse/partner have had a

financial interest/arrangement or affiliation with the organization(s)

listed below.

Affiliation/Financial Relationship Company

Pt M – 30 y/o F with BRAO

16hrs after airplane flight and PFO

30 mins s/p apraclonidine drops

Final diagnosis: Left ICA dissection and retinal embolism

… and incidental PFO

What is the underlying mechanism?

“Stroke is an observation not a

diagnosis”

Common mechanisms of cerebral ischemia

• “Small vessel disease” - lipohyalinosis

• Embolism

– Artery-to-artery (carotid, aorta, other)

– Cardiac source

– Paradoxical

• Decreased perfusion through a fixed stenosis

Other causes of cerebral ischemia

• Vasculitis

• Collagen vascular diseases: isolated angiitis of the CNS, temporal (giant cell) arteritis, polyarteritis nodosa, Wegener's granulomatosis, Takayasu's arteritis, syphilis

• Meningitis: tuberculosis, fungi, syphilis, bacteria, herpes zoster

• Arterial dissection: carotid, vertebral, basal intracranial arteries

• Hematologic disorders: polycythemia, thrombocytosis, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, dysproteinemias, hemoglobinopathies (sickle cell disease)

• Miscellaneous: cocaine, amphetamines, moyamoya disease, fibromuscular dysplasia, CADASIL

• Hypercoagulable states: secondary to systemic disease, carcinoma (especially pancreatic), eclampsia, oral contraceptives, lupus, factor C or S deficiency, factor V mutation, etc.

• Vasospasm: following subarachnoid hemorrhage

• Reversible cerebral vasoconstriction: idiopathic, eclampsia, trauma

• Venous: Dehydration, pericranial infection, postpartum and postoperative states, systemic cancer

Stroke mimics and chameleons

Lancet Neurol 2011, 10: 550-60

Stroke mimics

• Migraine

• Seizure

• Subdural hematoma

• Tumor

• Syncope

• Cardiac arrhythmia

• Panic attack

• Hypoglycemia

• Demyelinating disease

• Amyloid angiopathy

• Brain abscess

• Encephalitis

Stroke chameleons

Condition Prevalence

Altered mental status 31%

Syncope 16%

Hypertensive emergency 13%

Systemic infection 11%

Suspected acute coronary syndrome 10%

Other (seizure, peripheral vertigo, cord compression,

myasthenia gravis, Bell palsy, migraine, hypoglycemia)

20%

J Stroke Cerebrovasc Dis 2014 23: 374-378

Do I know what “neurologists” think?

Authors by specialty

Neurology Internal Med/Cardiology Other

Ovbiagele Kernan (IM) Heck: Radiology

Chimowitz Black (IM) Mitchell: Nursing

Fisher Bravata(IM) Richardson: Statistician

Furie Ezekowitz (C) Wilson: Neurosurgery

Johnston Fang (IM) Hepburn-Smith: Nursing

Kasner Rich (C) Mack: Neurosurgery

Kittner Panagos: ED

Schwamm

Gorman

Rabinstein

n=10 n=6 n=7

Classification of Recommendations and

Level of Evidence

2011

2014

Classification of Recommendations and

Level of Evidence

2011

2014

Recommendation should be changed

• Class III definition changed

• Committee erred in interpreting “negative trials”

• Evidence using the committee’s own words support at least IIb

It may never come to this...

CARDIOLOGIST NEUROLOGIST

Slide courtesy of Vincent Thijs, MD

Suggestions

1. Neurologists and cardiologists must collaborate

2. Involve neurologists in the diagnosis of stroke

3. Exclude other common “cryptogenic” causes: PAF, aortic atheroma, lacunes

4. Not every dizzy spell is a TIA

5. Continue aggressive risk factor modification after closure

6. Continue antithrombotic medication after closure

7. Involve patients in the decision making

8. Intersociety position statements