A Case of Complex PFO Leading to Ischemic Stroke: A Practical Clinical Pearl for Neurohospitalists

Patent foramen ovale (PFO) has been proposed as a mechanism for cardioembolic stroke, especially in younger patient populations. Complex PFOs, with tunnel lengths exceeding 8 mm, lead to a higher risk of neurological sequelae than simple PFOs and may also be harder to detect with transthoracic echocardiography (TTE). In this article, we present a 29-year-old woman who, after polypharmacy overdose, developed deep venous thrombosis and multiple pulmonary emboli (PE) and subsequent cardioembolic stroke. Initial TTE showed intact interatrial septum with late appearance of agitated saline in the left atrium after the seventh cardiac cycle. Subsequent transesophageal echocardiography, after treatment of PE with an intravenous thrombolytic (alteplase) and anticoagulation with heparin, showed a complex PFO with a 19-mm overlap of the septum primum and secundum without active flow. It is suggested that this PFO allowed for flow only in the situation of elevated right heart strain with PE, causing cardioembolic stroke and detection of agitated saline in the left atrium on TTE. However, under normal physiological situations, which resumed after treatment of PE with alteplase and heparin, the PFO did not allow for flow. This case demonstrates the potential importance of recognition of complex PFOs in diagnosis and management of cardioembolic stroke.