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Background: Clinical trial evidence supports patent foramen ovale (PFO) closure to reduce recurrent stroke risk in select patients. Guidelines recommend a multi-disciplinary approach to identify patients who may benefit from PFO closure. We assess factors associated with the decision to close PFO in a real-world cohort. Methods: We studied patients from University of Minnesota Medical Center and Yale-New Haven Hospital with TIA or ischemic stroke and PFOs evaluated by dedicated multidisciplinary teams of vascular neurologists and interventional cardiologists at each institution. Demographic, clinical, radiographic, and echocardiographic information was extracted by chart review. The study outcome was PFO closure. Descriptive analyses were performed comparing characteristics associated with PFO closure using Mann Whitney test and Chi-squared test. Multivariable logistic regression model was built with variables significant in descriptive analyses. Results: The analytic cohort included 173 patients, of whom 58 patients (33.5%) underwent closure (39.8% of Yale and 20% of UMMC patients were closed). Patients who were closed versus not were similar in age (median age 56 [IQR 21] versus 58 [IQR 21] years), sex, race, diagnosis of TIA or stroke, and co-morbidities except malignancy which was significantly less prevalent among closed patients (2.3% versus 12.1%). Closed patients had a higher RoPE score (median 6 versus 5, p=0.032), and were more likely to have a stroke or TIA of undetermined etiology (55.2 versus 49.6%) and high-risk PFO characteristics (p Conclusions and Relevance: In this study of a real-world cohort, we identify patient characteristics that drive decision-making for PFO closure for secondary stroke prevention.

Background and ObjectivesAlthough moderate and severe traumatic brain injury (TBI) can cause posttraumatic epilepsy (PTE), many patients with functional seizures (FS) also report a history of mild TBI. To determine whether features of TBI history differ between patients with epileptic seizures (ES) and FS, we compared patient reports of TBI severity, symptoms, and causes of injury.MethodsWe recruited patients undergoing video-EEG evaluation for the diagnosis of ES, FS, mixed ES and FS, or physiologic seizure-like events at an academic, tertiary referral center. Patients and their caregivers were interviewed before final video-EEG diagnosis regarding their TBI histories, including concussive symptoms and causes of injury.ResultsOf 506 patients, a greater percentage of patients with FS reported a history of TBI than patients with ES (70% vs 59%, aOR = 1.75 [95% CI: 1.00–3.05],p= 0.047). TBI with loss of consciousness (LOC) lasting less than 30 minutes was more frequently reported among patients with FS than with ES (27% vs 13%, aOR = 2.38 [1.26–4.47],p< 0.01). The proportion of patients reporting other neurologic symptoms immediately after TBI was not significantly different between FS and ES (40% vs 29%,p= 0.08). Causes of TBI were found to differ, with TBIs caused by falls from a height (17% vs 10%, aOR = 2.24 [1.06–4.70],p= 0.03) or motor vehicle collisions (27% vs 11%, aOR = 2.96 [1.54–5.67],p< 0.01) reported more frequently in FS than ES.DiscussionOur findings further the association of mild TBI with FS and prompt reconsideration of typical assumptions regarding the significance of a reported TBI history in patients with previously undifferentiated seizures. Although common in both groups, TBI with LOC less than 30 minutes and causes of injury that are commonly believed to be more severe were reported more frequently in FS than ES. This suggests that a patient or caregiver reporting of these features does not imply that PTE is a more probable diagnosis than FS. Although a history of TBI with LOC and presumed high-risk causes of injury intuitively raises suspicion for PTE, clinicians should be cautioned that these historical factors also were a frequent finding in patients with FS.