PFO: to close or not to close?

Background: Patent foramen oval (PFO), an anatomical variant of the interatrial septum associated with stroke via paradoxical embolism, is common, occurring in up to 25% of the general population. It is present in 40% of adults with cryptogenic stroke (CS). We present a CS and evidence of PFO. Case Report: A 64-year-old woman with a history of high blood pressure and nichel allergy, was admitted to the emergency department for right hemiparesis and suspicion of stroke. CT with contrast showed a focal left occipito-temporal hypo density of recent embolic nature for occlusion of the left posterior cerebral artery. 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. Initial investigations revealed no evidence of atrial fibrillation or large vessel disease. Further investigation with transthoracic, bubble contrast and transesophageal echocardiogram all indicated the presence of a PFO with left> right shunt. According to the cardiologist and the neurologist, she was candidate to PFO closure, taking into account nickel allergy for the choice of the device. Conclusion: The management of patients with CS and PFO remains a challenge. Based on current evidence, PFO closure is of moderate benefit compared to antiplatelet therapy alone in the prevention of recurrent ischemic stroke in adults up to 60 years of age, but above all patient perspective is the key. Our patient is reflecting on the decision to make.

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