PFO with High-Risk Features After Cryptogenic Stroke in Adults Aged 18–60

This protocol covers adults aged 18 to 60 who have had a cryptogenic stroke and are found to have a patent foramen ovale with at least one high-risk anatomical feature — in the absence of any other identified cause of stroke.

Clinical scenario

The patient is aged 18–60 years and has sustained a cryptogenic stroke. Transoesophageal echocardiography (TOE) demonstrates a PFO with a high-risk feature: a large right-to-left shunt of more than 20 bubbles reaching the left atrium, and/or an atrial septal aneurysm with excursion exceeding 10 mm from the midline.

No other evident cause of stroke has been established. This combination — younger adult, cryptogenic event, high-risk PFO morphology — defines the sub-population for whom a definitive interventional strategy is supported by high-quality evidence.

Management approach

The evidence-based approach involves a percutaneous closure procedure combined with antiplatelet therapy. There is also a specific antiplatelet sequencing component to the regimen — the full protocol, including timing and sequencing details, is available via the link below.

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References

The Pascal classification system recommends PFO closure plus antiplatelet therapy in selected patients aged under 60 years (essentially those with a large right-to-left shunt or an atrial septal aneurysm), without other evident cause of stroke.
In patients aged 18–60 years without other evident cause of stroke but a PFO, PFO closure in selected patients is recommended in addition to antiplatelet therapy (Quality of evidence: High - Strength of recommendation: Strong for intervention).
In patients aged 18–60 years with possible or probable PFO related stroke according to the PASCAL classification, PFO closure in addition to antiplatelet therapy is recommended (Quality of evidence: Moderate - Strength of recommendation: Strong for intervention).
A large shunt size is defined as >20 bubbles in the left atrium on TOE; ASA defined as >10 mm of excursion from midline.
PFO closure is suggested within 6 months post index stroke, based on randomised studies.
In patients undergoing PFO closure, dual antiplatelet therapy is suggested followed by single antiplatelet therapy to reduce the risk of recurrent stroke, based on the protocol of available RCTs (Quality of evidence: Low - Strength of recommendation: N/A).

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