TTE detects PFO with only about half the sensitivity of TEE. If TEE is negative or unavailable and suspicion remains high, transcranial Doppler with bubble contrast is the recommended alternative. Daily aspirin 300 mg is associated with low recurrent stroke rates. Newer disc occluder devices (e.g., Amplatz PFO occluder) have demonstrated superiority over medical therapy in pooled analyses for high-risk PFOs.

PFO is the likely cause of cryptogenic stroke in approximately 50% of cases where both are present.Clinical clues for PFO-related stroke: young age, no traditional risk factors, Valsalva-triggered onset, DVT, PE, hypercoagulable state, migraine with aura, large or multi-territorial infarcts on MRI.TTE has approximately half the sensitivity of TEE for PFO detection.Transcranial Doppler with bubble contrast is the recommended alternative when TEE is negative or unavailable.First-line treatment: antiplatelet therapy (aspirin 300 mg daily).Warfarin has similar or slightly superior efficacy to aspirin, especially for cortical infarcts.Newer oral anticoagulants have not been formally tested for PFO but likely benefit paradoxical embolism cases.Newer disc occluder devices reduce recurrent stroke risk in high-risk PFO cases per pooled analyses.PFO closure complications: AF, femoral hematoma, cardiac tamponade, device embolization (reduced with newer devices).PFO closure benefit is limited to high-risk PFOs (moderate-to-large shunt with atrial septal aneurysm).