Patent Foramen Ovalea and Stroke

[beverly]

I have been seening a nuerologist for migraine headaches. April 98 my left arm went numb, I could use it but no feeling. About a week after I got a sever Migraine. Then numbeness lasted a few weeks. Feeling all came back except the tip for left fingers. No problems except Migraines until Feb 99 when my left face became numb, like I had been to the dentist. Again no headache at the time. Felt fine otherwise. About 12 hours later the feeling came back. Every day sinec then I have had tingling and numbness in left face, arm,fingers, and somestimes left left leg and foot. Always left side. Had a Nerve conductor test, no periherial damage, no carpal tunnel. MRI showed multiple white dots, about 20 on left side, about 4 on right side, msotly frontly lobe. About the size of a BB pellet kids use in BB guns. Radiologist said emboli likely crossing into brain. Possible MS. Nuerologist said I do not have any symptoms for MS and did echo with bubble contrast. Cardiologist present said a patent foramen ovale was present with blood flowwing even at rest. Nuerologist strongly recommended closure, due to stroke risk. Cardiologist also strongly recommended closure. Said he didn't think I could have transcather closure because balloons migrate. Both of these doctors sent me to a cardia surgeon who said he wouldn't do surgey unless I had a stroke first. Felt surgery was too high risk, MRI didn't show infaract, but he said emboli was probaly crossing through the hole in my heart.Transcathter not done in Hawaii yet. I could come to Cleveland. Cardiologist there on forum said transcathter would  be a option, and I should ahve the hole closed.
I AM SO CONFUSED, I DON't KNOW WHAT TO THINK. SHOULD I FOLLOW UP ON THIS OR TAKE MY ASPIRIN A DAY AND WAIT UNTIL AFTER I HAVE A STROKE.AM I AT HIGH RISK FOR THAT. I am 43, 113il never smoked or drank, no ohter risk factors for stroke exce

[CCF Neuro[P] MD, RPS]

Dear Beverly:

Sorry that you have had such trouble with your migraines.  The question is whether you have right to left blood flow through the patent ovale during normal activity.  Usually, the left sided pressure of the heart prevents such flow and therefore any chance of emboli transfersing to the left side of the heart (emboli cannot travel against a gradient) and theoretically produce a stroke.  Otherwise the emboli get trapped in the lung and do little harm to the brain (the right heart circulates to the lungs).  Since you have no risk factors for stroke: atrial fibrillation, hyperdynamic septum, vegetations on your mitral value that is good.  Any of these or right to left blood flow, one would begin to think about ovale closure.  

Alot of perfectly normal people of small bright spots on their MRI.  These mean very little.  Areas of demyelination near the ventricles or in the temporal lobe are worrisome and could indicate MS.  Yours are not in the usual pattern.

Whether to get the closure is sort of a personal thing.  If you were my wife, I better say my mother, if she had any of the above risk factors I would recommend closure.  I thing that the evidence for the new clamp/umbrella procedure is quite good and also non-invasive (they do it throu an artery)for closure.  If there were other risk factors such as hypercoagulable state, hypertension, hyperlipidemia, diabetes, family history, I think that you might make the decision to have the procedure.  Remember, that up to 30% of females have a patent ovale and the risk of stroke in this population doesn't seem to be greater than the population at large, with the exception of the risk factors mention.

I hope this helps.

Sincerely,

CCF Neuro MD

[beverly]

Dear Dr.
     Thank your for your response. My doctor has decided to trat this with medication. I do not have a right to left shunt, but because she says some of the places on my MRI scan indicate a TIA she wants me to take 75mg a day of Plavix to prevent further clottine and emboli from crossing, and she has prescribed 500mg a day of Depakote. She feels if we get rid of the migraines the numness and tingling on my left side will go away. She feels ome of it is from the PFO and some from complicated migaines. I do not want to take depakote, after reading all the side effects of this medication it does not seem worht it. Is 500mg a day enough to make my hair fall out, cause fatigue, and gian weight. I have been checked for Lupus and she says everthing else she can think of that would cause the tingling and numbness. It doesn't make since to me that I would all of a sudden get this from migraines I have had for 7 years and a hole in my heart I have had for 43 years. What do you think, should I get a 2nd opinion, and from who, a nuerologist, a cardiologist, or who? She says I am at risk for a stroke but doesn't trust the closure method because it can slip, and the surgery we have decided is too risky.
I feel like from your response I am not really at risk for anything...Thank you for any advice..Aloha, bev

[CCF Neuro[P] MD, RPS]

Dear Bev:

With the older clamping devices I would agree with your physician, but not with the newer generation.  But, since you have no right to left shunt, your chances for a stroke are almost nil.  As far as valproate, I would agree with you and I do not prescribe this medication to women after puberty.  However, she must have a reason and I would follow her advice.  As far as plavix, it is a good medication.  However, if your white spots are not in a vascular distribution then I would think that first line is aspirin (it is in all the studies thus far, we use plavix only after aspirin failure or intolerance). If you decide that you need a second opinion, I would see a neurologist who specializes in stroke.  Best of luck,

Sincerely,

CCF Neuro MD

[Bev]

I have just seen another cardiologist who looked at the tape of my echo with bubble contrast. He has told me my PFO is very small and that blood is crossing over from right to left but in trace amounts. He said he didn't think a large clot could get through, only small ones. I don't understand how they can have so many different dx. I had a nuclear test that said I do not have a right to left shunt, he says I do, but in small amounts.
Can you tell me:  
1. Can small clots passing across cause a stroke? He said he didn't think so, nuero thinks that is why I have all the spots on my MRI.
2. Is there something else I could suggest to my nuero that would explain the tingling and numbness I get just on my left side, daily in the face, worse in left arm and foot if I have a headache, mild or otherwise, and chest pains. She said she feels she has ruled everthing else out and this is complicated migraines with stroke like symtoms. I get the tingling and numbness as soon as I get up, and start moving around. Even if I have no other symptoms.
Thank you for your consideration. Bev

[CCF Neuro[P] MD, RPS]

Dear Bev:

It is difficult to tell you what to do.  We routinely use the newer generation clamping device for PFO closure.  If the bubble test shows right to left shunt, then there is the theoretical chance for small clots to cross the heart and go to the brain. Yes, small clots can induce strokes.  Whether the small bright spots on your MRI are do to small clots is probably not known.  It is alittle worrisome to have more on the left than the right side of your brain.  But what you need to know is that many people have bright spots on their MRI without a PFO and without any effects.  My worry would be since you have had symptoms in the past that might suggest some small strokes.  I think if you were here at the Cleveland Clinic, we would recommend a clamp, if and only if we thought the bright spots were strokes.  

If the daily symptoms were being caused by strokes, your brain would look really, really bad.  Usually, stroke symtpoms are limited and will resolve with a remaining deficit.  Your symptoms are continuous that would rule out stroke as a cause of these symptoms, with the MRI you describe.  I can't tell you what your symptoms are from because I can't examine you.  MS might give you symptoms that persist but your lesions do not sound like demyelinating lesions nor are they in the usual location.  

You will have to make a decision about a second opinion concerning the clamp device.  It might be a good idea to get a fresh opinion from a place that places the new clamp device and see what their opinion might be.  Be sure that you balance that opinion with what your getting now.

Sincerely,

CCF Neuro MD

[beverly]

I am now currently taking plavix, for about 2 months. Last week while sitting a my desk and talking with a client I suddenly felt somthing come ove me. I was very confused, had difficulty understanding the person, had to keep asking them to repeat theirselves, I could talk without any slurring but the words that I wanted to say came out different. I got very nauseated and my left face, arm and hand got very tingly and numb. I had to hang up. I got up to go to he bathromm and felt very weak. This lasted about 20 min then all the symptoms went away except I was left feeling shaky and nausea for about 1 hour, then back to normal. I had no pain at all. Later in the day I had a dull ache in the back of my head. Very mild. My nuerologist said she thinks thins is a complicated migraine. I do have migraines and on Doxepin for 1 month, no change, but have never had anything like this happen to me, except once I had crushing pain in the chest with same symptoms, no confusion or speaking problems though. I have a small PFO still, dctors here still debating closure. Does this sound like a complicated migraine or a Tia?
I have noticed at other times lately when I talk to someone, even though I clearly know what I want to say I use toally different words that do not make sense. Any connection?
Thank you for your opinion.

[CCF Neuro[P] MD, RPS]

Dear Bev:

It is difficult to say.  I would pursue the TIA angle initially because you want to know that it wasn't.  If it was then you need the umbrella we mentioned before.  A diffusion weighted MRI might be helpful.  I would ask for one.  If the diffusion is normal then I would agree with the migraine angle.

Sincerely,

CCF Neuro MD

[Karen]

I'am a 43 year old tripple bypass patient i'am presently showing signs that i might of had a stroke i've had a tia in the past and iam so nervous right now because iam waiting to have a cat scan done and a ulrta sound done in the mean time iam experecing numbness and tingling on my left side i'am also a diabetic ........... thank you karen

[Karen]

I'am a 43 year old tripple bypass patient i'am presently showing signs that i might of had a stroke i've had a tia in the past and iam so nervous right now because iam waiting to have a cat scan done and a ulrta sound done in the mean time iam experecing numbness and tingling on my left side i'am also a diabetic ........... thank you karen

[CCF Neuro[P] MD, RPS]

Dear Karen:

If you think your having a stroke, don't wait for the CT: GO, GO to the emergency room: NOW!!!!!

CCF Neuro MD