AAN PFO Guidelines Bundle

© 2020 American Academy of Neurolog y Institute Recommendations Regarding Percutaneous PFO Closure ➤ In patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke, as was performed in all positive PFO closure trials (B). ➤ In patients being considered for PFO closure, clinicians should obtain brain imaging to confirm stroke size and distribution, assessing for an embolic pattern or a lacunar infarct (typically involving a single deep perforator <1.5 cm in diameter) (B). ➤ In patients being considered for PFO closure, clinicians should obtain complete vascular imaging (MRA or CTA) of the cervical and intracranial vessels to look for dissection, vasculopathy, and atherosclerosis (B). ➤ In patients being considered for PFO closure, clinicians must perform a baseline ECG to look for atrial fibrillation (A). ➤ Select patients being considered for PFO closure thought to be at risk of atrial fibrillation should receive prolonged cardiac monitoring for at least 28 days (B). Note: Risk factors for atrial fibrillation include: age ≥50 years, hypertension, obesity, sleep apnea, enlarged left atrium, elevated NT-proBNP, frequent premature atrial contractions, and increased P wave dispersion. Recently published guidelines from the American Heart Association, American College of Cardiolog y, and Heart Rhythm Society recommend prolonged ECG monitoring following cryptogenic stroke for patients older than 40 years, although more research is needed to define the yield in unselected young patients and in patients with PFO. 1 ➤ In patients being considered for PFO closure, clinicians should assess for cardioembolic sources using TTE, followed by TEE assessment if the first study does not identify a high-risk stroke mechanism. Studies should use bubble contrast, with and without Valsalva maneuver, to assess for right-to-left shunt and determine degree of shunting (B). ➤ In patients being considered for PFO closure, clinicians should perform hypercoagulable studies that would be considered a plausible high-risk stroke mechanism that would lead to a change in management, such as requiring lifelong anticoagulation (e.g., persistent moderate- or high-titer antiphospholipid antibodies in a younger patient with cryptogenic stroke) 2 (B). ➤ In patients being considered for PFO closure, clinicians may use TCD agitated saline contrast as a screening evaluation for right-to-left shunt, but this does not obviate the need for TTE and TEE to rule out alternative mechanisms of cardioembolism and confirm that right-to-left shunting is intracardiac and transseptal (C). Key Points Management ➤ For patients with cryptogenic stroke and PFO, percutaneous PFO closure probably reduces the risk of stroke recurrence (HR-0.41, summary rate difference -0.67% per year), probably is associated with a periprocedural complication rate of 3.9%, and probably is associated with the development of serious non-periprocedural atrial fibrillation (RR-2.72, summary rate difference 0.33% per year). ➤ For patients with cryptogenic stroke and PFO, anticoagulation medication and antiplatelet medication are possibly equally effective at reducing recurrent stroke. Summary of Clinical Questions ➤ The 2 clinical questions addressed in the 2016 Update of the 2004 Practice Parameter remain unchanged in this 2020 Update. • The first clinical question deals only with percutaneous PFO closure. • The second clinical question concerns medical therapy and determined that anticoagulation and antiplatelet therapy are possibly equally effective at reducing recurrent stroke. Patent Foramen Ovale Secondary Stroke Prevention

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