Cryptogenic stroke and patent foramen ovale

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Purpose of review

Controversy surrounds the issue of patent foramen ovale (PFO), stroke, and secondary prevention strategies. Paradoxical embolism is usually a presumed diagnosis, incidental PFOs are common, and treatment options have not been well compared.

Recent findings

Paradoxical embolism occurs at any age. The most likely potentiator of stroke risk in patients with cryptogenic stroke and PFO is a concomitant atrial septal aneurysm. PFO size, degree of shunting, and a coexisting hypercoagulable state may be additional risk factors. In addition to deep lower extremity veins, superficial and pelvic veins are increasingly identified as sources of embolism. Treatment options include antiplatelet agents, anticoagulants, surgical closure, or percutaneous closure devices. Recent studies have provided comparative data of different PFO closure devices.


Strategies for distinguishing incidental PFOs from pathogenic ones in cryptogenic stroke patients and for identifying patients at high risk of recurrence are needed. Off-label implantation of non-PFO closure devices in trial-eligible patients continues. Participation in ongoing, randomized clinical trials comparing closure devices with medical management is recommended by the Food and Drug Administration and professional societies. The trials will clarify if the risks of invasive endovascular device placement are outweighed by a long-term reduction in recurrent vascular events.

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