A PFO is a common heart defect, and has nothing to do with alligators. But like alligators, PFOs can be hidden, silent and deadly.
Full disclosure. I am not a doctor. I do not work in the medical field. I have zero medical training. I’m writing based only on my personal experience.
“PFO” stands for patent foramen ovale. Ever hear someone say they “have a hole in their heart”? This is likely what they mean. It’s a hole between the two upper chambers.
In three sentences, here’s the take away: If you have migraines, especially with auras, you may have a PFO. If you have a PFO, you have a higher risk of having a stroke. If you suspect a stroke, get to the ER as soon as you can.
Getting back to the details and my layperson’s understanding of anatomy, the heart has four chambers. The upper right and left chambers, or atria, and the lower right and left chambers, or ventricles. Spent blood flows into the upper right atrium, then down to the lower right ventricle, and into the lungs. The lungs work their magic replenishing the oxygen and filtering the blood. That blood is pumped into the left atrium. From there, it goes down to the left ventricle and then out through the body.
Simplified heart blood flow diagram
In utero, the fetus does not need lungs to oxygenate its blood. All the blood comes from mom, pre-oxygenated and pre-filtered. (Yeah moms!!) There’s no need for the loop through the fetal lungs. Instead, the blood flows into the right atrium, then through the foramen ovale directly into the left atrium, and then down to the left ventricle and through the body.
Everyone has a foramen ovale in utero, and in most people, a flap closes the hole shortly after birth. But in about 25% of the population, that flap does not completely seal. Thus the foramen ovale remains open or “patent.” This means that blood can be “shunted” from the right upper chamber into the left chamber.
It’s possible to live an active and healthy life and never know you have a PFO. I did until I was 64. My dad did until he was 80. Both of us discovered our heart defects in the ICU after a stroke. Turns out a stroke is not uncommon in patients with a PFO. But association is not causation.
Strokes can be divided into those with a known cause and those with an unknown cause (cryptogenic). I had a cryptogenic stroke. My PFO is suspected of causing my stroke, but that could not be determined 100%. Even though the doctors ruled out everything else that they knew to check for, that’s not good enough for causation. Yet consider that studies have shown that a PFO was present in 40 to 50% of stroke patients who had cryptogenic strokes.
In some cases, doctors can determine that a PFO caused a stroke. The mechanism is a paradoxical embolism, which is an
Embolism arising from the venous circulation that enters the arterial circulation by crossing from the right side of the heart to the left side through a patent foramen ovale or septal defect.
In other words, the embolism is shunted from the right atrium, through the PFO, to the left atrium without being filtered by the lungs. If that embolism lands in the brain, it causes a stroke. (More info here here.)
If you get to the ER promptly and had an ischemic stroke, (info here here on other forms of stroke), you may be able to receive tissue plasminogen activator (tPA), a super strong clot buster, given by IV. TPA can only be administered within a limited time from the onset of symptoms. (Past that window, the risks may outweigh the benefits.) With the clot dissolved, blood flow resumes in that area of the brain, minimizing the damage. Absent tPA, that part of the brain is dead. Period. You have to relearn whatever was there.
Here’s a tip: If you suspect a stroke, even if you’re not sure, start the stopwatch function on your smartphone at the first sign of symptoms. This will give the medical personnel critical information to determine whether you are a candidate for the tPA treatment.
For me, the clot hit my speech, language and processing center, leaving me unable to speak (aphasia), except for basic words. Like yes and no. Everything else came out an unrecognizable slur (dysarthria). The impact of the tPA was dramatic. By the end of the 60 minute treatment, I was able to talk, although I was still missing a large chunk of vocabulary. When asked what year it was, I couldn’t say “two thousand twenty,” but I could say “two zero two zero.” My cognitive abilities also remained impaired, and I needed therapy. A year-and-a-half post-stroke, I have some minor permanent damage. No one notices but me and Mr. C.
So what is the connection with migraines? A neurologist told me years ago that, because of my history of migraines with auras, I have a statistically significant higher risk of stroke. His recommendation was to take a baby aspirin daily. I did so for years and still do. I wasn’t aware of the added connection with PFOs until the hospital neurologist took a detailed medical history and migraines came up, including that I’d had one the day before the stroke. He explained that there is a poorly understood relationship between PFOs, migraines and strokes.
As to the mechanics of that relationship, currently there are just theories. One is that the shunted blood bypasses the lungs and their filtering function. Small amounts of chemicals pass into left atrium and out into the blood stream, some landing in the brain and triggering a migraine. Another theory is that tiny blood clots form in the shunting, which trigger migraines when they land in the brain.
One other fact supports a connection. In many patients, after their PFO is closed, their migraines stop or decrease in frequency and intensity. In this study, migraines disappeared in 34% of patients and improved in an additional 48%.
I opted to have my PFO closed. (I don’t want this diary get TL;DR. So I’d be happy to explain the closure process in the comments if anyone is interested.) My experience post-closure is that I’ve had two migraines. Both were within four months of the closure – about average for my migraine history. It’s been over a year now and no migraines since then. PFO closure is not yet a recommended treatment for migraines, absent other indications.
Whether or not you suffer from migraines, be prepared. Know the signs of a stroke. The hospital’s resource material used the mnemonic FASTER:
Face: drooping, numbness, uneven smile. This doesn’t exactly involve the face, but a sudden severe headache with no known cause is also a sign.
Arm (or leg): weakness or numbness.
Stability: dizziness, difficulty balancing or walking, loss of coordination.
Talking: slurring words, inability to speak, difficulty understanding speech, confusion, inability to repeat a simple sentence.
Eyes: difficulty seeing out of one or both eyes, double vision.
React: call 911 immediately, even if the symptoms go away. Whatever you do, don’t try and “sleep it off.” Your window for treatment will close.
Also know the risk factors, which surprisingly do not include having a PFO. Here’s one:
One in 5 women will have a stroke.
Even being in that 20%, I consider myself fortunate in so many ways. I was teleworking that day. My city has Emergency Medical Service, with top notch professionals. The EMS station is a half mile from my home, and the ambulance was there in minutes. A hospital with a level one trauma center is less than four miles away. I had the stroke between the first and second waves of COVID, so the ER was able to triage me immediately and there were plenty of well-staffed and available beds. I got the tPA treatment. It was effective and I had no side effects. The neuro ICU doctors and staff were exceptional. I have employer-provided health insurance, which has covered all but minimal deductibles. I had all the paid sick time I needed with a boss and co-workers who couldn’t have been more supportive. And I had Mr. C, my rock, my comedian, my angel.
I’ve shared my experience with friends and family, and have encouraged them to tell others, especially about the connection among PFOs, migraines and stroke, and the benefits of tPA if you get to the hospital promptly. I’ve been told my story has been eye opening and valuable. In sharing it with the Daily Kos community, I hope others will find it so as well.
Wednesday, Jan 19, 2022 · 4:54:58 PM +00:00
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Clickadee
As FishOutofWater helpfully notes below, all of the fetal blood does not come from mom. It’s a bit more complicated than that, as the block quote explains, with the fetus having a totally separate blood supply. That blood is still circulated through the patent ovale, but it’s not directly from mom as I described.
Wednesday, Jan 19, 2022 · 8:01:44 PM +00:00
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Clickadee
Some of the comments have discussed tests to diagnose a PFO. avatarabbiehoffman chimed in with a great comment and crucial information:
I would just like to add that PFOs can be ruled out (or confirmed) by Echocardiography with Doppler. Your insurance may pay for it if you have documented history of migraines. Ask your doctor. :)
Here’s an NIH link with more information.