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Increased frequency of cardioembolism and patent foramen ovale in patients with stroke and a positive travel history suggesting economy class stroke syndrome


Objective: To investigate the frequency of acute stroke in patients with a recent travel history and to analyse risk factors, stroke patterns and presence of a patent foramen ovale (PFO) in this patient group.

Design: One-year prospective observational study.

Setting: Single-centre study.

Methods: Enrolling all patients presenting with a first cerebral ischaemia and complementing the usual history with a standardised travel history.

Results: Of 338 patients with acute stroke, 42 had a positive travel history (PTH) (12.4%). Patients with a PTH were significantly younger (56.6 (SD 13) years) than patients (66.9 (13.2) years, p  =  0.0001) with a negative travel history (NTH). Frequency of PFO in the PTH group (13; 44.8%) was significantly higher than in the NTH group (7; 10.8%) (p  =  0.0001), even after patients were dichotomised into two age groups (younger and older than median of all patients: 31% v 6.1%, p  =  0.007 and 13.8% v 4.6%, p  =  0.022, respectively). PTH patients had fewer stroke risk factors (2.2 (1.4) v 3.3 (1.6), p  =  0.0001) and a different risk profile with a lower frequency of diabetes (11.9% v 31.4%, p  =  0.009), hypertension (52.4% v 78.7%, p  =  0.0001), atrial fibrillation (7.1% v 22%, p  =  0.025) and others (16.7% v 38.9%, p  =  0.005). In contrast, PTH patients had significantly more cardioembolic (35.7% v 19.3%, p  =  0.023) and cryptogenic strokes (50% v 19.9%, p  =  0.0001) and more often ischaemia in the territory of the posterior cerebral artery (29.6% v 6.3%, p  =  0.0001).

Conclusions: The finding that more PTH patients had a PFO and a cardioembolic stroke pattern but that fewer had other typical stroke risk factors led to the hypothesis that PFO is a risk factor for economy class stroke syndrome.

  • CT, computed tomography
  • DVT, deep venous thrombosis
  • ECSS, economy class stroke syndrome
  • MRI, magnetic resonance imaging
  • NTH, negative travel history
  • PFO, patent foramen ovale
  • PTH, positive travel history
  • TOAST, Trial of Org 10172 in Acute Stroke Treatment
  • TOE, transoesophageal echocardiography

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