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(Stroke. 2004;35:803.)
© 2004 American Heart Association, Inc.

Controversies in Stroke

Patent Foramen Ovale and Recurrent Stroke: Closure is the Best Option: Yes

From the Department of Neurology, Cleveland Clinic, Cleveland, Ohio.

Correspondence to Dr Anthony Furlan, Cleveland Clinic, Cerebrovascular Center, Dept of Neurology, Desk S91, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195-5001. E-mail furlana@ccf.org

Key Words: foramen ovale, patent • stroke

An extract of the first 250 words of the full text is provided, because this article has no abstract.

Patent foramen ovale (PFO), a common congenital cardiac anomaly in the general population, is more prevalent among patients with stroke <50 years of age, especially patients with "cryptogenic" stroke. That a PFO can serve as a conduit for brain emboli is not in dispute. Right-to-left shunting is easily demonstrated on echocardiography with agitated saline. If the bubbles (ie, emboli) can get from the right heart to the left heart, they can get to the brain.

Although warfarin has been the "conventional" medical therapy for patients with PFO and transient ischemic attack (TIA) or stroke, there are few data to support its routine use and associated risk of bleeding. In a French study,¹ the 2-year risk of stroke or TIA was not increased in patients with cryptogenic stroke and a PFO alone treated with aspirin, but was increased from 4.7% to 8.0% in patients with PFO and atrial septal aneurysm. In the Patent Foramen Ovale in Cryptogenic Stroke Study (PICSS),² PFO was more prevalent among patients with cryptogenic stroke, but there was no significant difference in the 2-year rate of stroke and death in patients with or without PFO (14.3% versus 12.7%). There was also no significant difference whether PFO patients were treated with warfarin or aspirin. Unfortunately, while suggesting that the risk of recurrent stroke in patients with cryptogenic stroke and PFO is low even with aspirin, except perhaps in patients with atrial septal aneurysm, definitive conclusions cannot be drawn from available studies because the patient numbers are too small.

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