전향적 후향적 연구들은 acute PTE 환자들에서 PFO를 통한 embolism으로 인해 뇌졸중의 위험이 증가되었음을 시사해 왔습니다. 뇌졸중의 유병률은 평균 < 17%였고 PFO가 있는 환자들에서는 < 33%로 더 높았습니다. 최근 361명의 acute PTE 환자들을 대상으로 한 전향적 연구에서 PFO가 없는 환자들에 비해 있는 환자들에서 뇌줄중의 위험이 더 높았습니다(21.4 versus 5.5 percent; relative risk 3.5, 95% CI 1.62-8.67). 그러나 9명이 환자가 이 연구에서 불충분한 TTE 또는 MRI 검사로 배제되었고 PFO의 비율이 일반 인구보다 더 낮았다는 것은 이 결과들이 결함이 있음을 시사합니다. 추가 연구들이 있을 때까지는 일상적인 contrast echocardiography 또는 MRI 검사를 뇌졸중의 증상이 없는 acute PTE 환자에서 권고하지 않습니다.
●Stroke – Prospective and retrospective studies have suggested an increased risk of stroke, thought to be due to paradoxical embolism via a patent foramen ovale (PFO), in patients with acute PE . Prevalence rates of stroke have ranged from 7 to 50 percent (averaging <17 percent), with higher rates in those with PE who also have a PFO (21 to 64 percent, averaging <33 percent). Best illustrating this risk for stroke is a prospective study of 361 patients with acute PE who underwent contrast transthoracic echocardiography (TTE) and magnetic resonance imaging (MRI) of the brain (for silent or symptomatic stroke) within ten days after the diagnosis of PE. Stroke was diagnosed in 7.6 percent and PFO in 13 percent of patients with acute PE. Rates of stroke were higher in those who had a PFO compared with those who did not have a PFO (21.4 versus 5.5 percent; relative risk 3.5, 95% CI 1.62-8.67). However, nine patients were excluded from the analysis due to inconclusive TTE or MRI testing and the rate of PFO was lower than that in the general population (approximately 25 to 30 percent) suggesting that these results are flawed. Further studies are recommended before we can support a recommendation to routinely perform contrast echocardiography (transthoracic or transesophageal) or MRI imaging in patients with acute PE who have no symptoms of stroke. Accordingly, we prefer a symptom-directed approach such that vigilant surveillance for neurologic symptoms is appropriate in those with acute PE and the presence of stroke should prompt a search for a PFO. Whether the discovery of a PFO with PE and stroke should prompt indefinite anticoagulation and/or PFO closure is also unknown such that a multidisciplinary approach with a pulmonologist, neurologist, and cardiologist is prudent. Management of patients with stroke and PFO is discussed separately.
REF. UpToDate 2019.10.29
