Management of Cryptogenic Ischemic Stroke with Patent Foramen Ovale (PFO)
For patients under 60 years with cryptogenic ischemic stroke and PFO, PFO closure plus antiplatelet therapy is strongly recommended over antiplatelet therapy alone when extensive workup for other stroke etiologies is negative. 1, 2
Treatment Algorithm Based on Patient Factors
First-Line Management:
- For patients under 60 years who are open to all options, PFO closure plus antiplatelet therapy is recommended over anticoagulant therapy (weak recommendation) 1, 2
- For patients with contraindications to anticoagulation, PFO closure plus antiplatelet therapy is strongly recommended over antiplatelet therapy alone 1
- For patients in whom closure is contraindicated or declined, anticoagulant therapy is weakly recommended over antiplatelet therapy 1
Efficacy of PFO Closure:
- PFO closure reduces the risk of recurrent stroke compared to antiplatelet therapy alone (hazard ratio 0.23; 95% CI: 0.09-0.62) 3
- The effect is more pronounced in patients with atrial septal aneurysm or large shunt (RR=0.27,95% CI: 0.11-0.70) 4
- The annual absolute risk reduction is low but significant given the substantial time at risk (at least 5 years) in young and middle-aged patients 4
Procedural Considerations for PFO Closure
- The procedure typically takes under 2 hours with an in-hospital stay of usually one day 1, 2
- Most activities can be resumed within a few days, with full recovery within a few weeks 1, 2
- Serious device-related adverse events occur in approximately 1.4% of patients 3
- New-onset atrial fibrillation is more frequent after PFO closure (6.6% of patients) compared to medical therapy alone 3
Medical Therapy Options
- If PFO closure is not performed, antiplatelet therapy options include aspirin (75-325 mg daily) 2
- For patients in whom closure is contraindicated or declined, anticoagulation therapy (such as warfarin with target INR 2.0-3.0) is weakly recommended over antiplatelet therapy 1
- Anticoagulation compared to antiplatelet therapy may reduce the risk of ischemic stroke recurrence (RD -71,95% CrI -100 to +17) but probably increases the risk of major bleeding (RD +12,95% CrI -5 to +65) 5
Important Considerations and Caveats
- These recommendations apply specifically to patients under 60 years with cryptogenic ischemic stroke and PFO when extensive workup for other stroke etiologies is negative 1
- The applicability of these findings to patients over 60 years and those with traditional cerebrovascular risk factors (diabetes, hypertension, hyperlipidemia) is more uncertain 1
- In older patients, fewer cryptogenic strokes are caused by paradoxical emboli, so the benefits of PFO closure would likely be smaller and the risks potentially greater 1
- Transesophageal echocardiography is recommended for detailed visualization of atrial septal anatomy when PFO closure is planned 2
- For patients with concurrent atrial fibrillation, anticoagulation would be indicated regardless of PFO status 2