Stroke and patent foramen ovale: intervene or wait

A 33-year-old woman presented to the emergency department with an acute left partial anterior circulation ischaemic stroke. Thrombolysis was not administered due to a rapidly improving National Institutes of Health Stroke Scale (NIHSS) score and she was thereafter given appropriate treatment for secondary prevention. CT and MRI demonstrated a left basal ganglia infarct with haemorrhagic transformation. Initial investigations revealed no evidence of atrial fibrillation or large vessel disease. Further investigation with transthoracic, bubble contrast and transoesophageal echocardiogram all indicated the presence of a grade 1 tunnel-shaped patent foramen ovale (PFO) with some aneurysmal interatrial septum. No other cause for her stroke was found. There is no current evidence to support the routine use of percutaneous PFO closure in prevention of stroke or transient ischaemic attack. National guidelines advise transcatheter closure of PFO should only be considered for patients with recurrent cryptogenic stroke on optimal medical management.