Patent Foramen Ovale and Cryptogenic Stroke: To Close or Not to Close? Closure: What Else!

A 39-year-old mother of 2 teenage boys complained of severe migraine with aura for >10 years. Otherwise healthy, she suffered an ischemic stroke that rendered her permanently aphasic. Diagnostic evaluation revealed no evidence of atherosclerosis of the carotid arteries or plaques of the ascending aorta and the aortic arch. The ECG showed normal sinus rhythm, and the patient denied any history of palpitations or arrhythmias. Echocardiography documented normal ventricular function without wall motion abnormalities or evidence of thrombus and normal-appearing valves but a large patent foramen ovale (PFO). The most likely clinical diagnosis is stroke due to paradoxical embolism. The patient’s neurologist recommended PFO closure. However, guidelines regarding PFO closure from professional societies remain ambiguous because of insufficient evidence regarding therapeutic measures (Table 1).1,2 View this table:Table 1. Guidelines From Professional Societies 1,2Response by Messe and Kasner p 1998 Stroke is the third leading cause of mortality and the most important cause of serious, long-term disability in developed countries.3 The presented case is testimony to the sad sequelae of stroke that may deprive someone permanently of speech, an emotional and mental tragedy. A classic etiology is not found in up to 40% of ischemic strokes despite an extensive diagnostic evaluation. This is referred to as cryptogenic stroke , a term that strangely ignores the role of the PFO.4 The foramen ovale is an opening in the atrial septum secundum, with the septum primum functioning as a 1-way valve allowing right-to-left shunt during in utero development. The postnatal decrease in right atrial pressure results first in functional followed by anatomic closure in the ensuing months. Autopsy studies show that fusion of the 2 septae fails to occur in ≈1 of 4 people.5 This is referred to as PFO and represents the most common congenital abnormality.6 Paradoxical …