Abstract Background Cryptogenic stroke accounts for approximately 25% of all ischemic strokes, and among these, patent foramen ovale (PFO) is recognized as a potential cause. While PFO closure has demonstrated superiority over medical therapy for secondary stroke prevention in patients younger than 60 years, data on patients aged 60 years and older are lacking. The Risk of Paradoxical Embolism (RoPE) score is a useful tool for estimating the contribution of PFO to stroke occurrence. Additionally, the PASCAL score integrates RoPE with high-risk PFO features such as atrial septal aneurysm and large shunt, using a RoPE score of 7 or higher as a key indicator. Since the maximum RoPE score for patients aged 60 or older is 6, the association between PFO and stroke is generally considered lower. However, cases of multiple strokes have been observed in this population, suggesting that even patients with a low RoPE score might still benefit from PFO closure. Objective To analyze anatomical risk factors and patient characteristics in first-episode and recurrent cryptogenic stroke patients with PFO undergoing catheter-based closure, identifying factors associated with recurrent stroke. Methods We retrospectively analyzed cases of PFO closure performed at our institution from 2020 to 2024. Patients were classified into first-episode and recurrent stroke groups, and comparisons were made regarding anatomical risk factors and patient background. Results Among 58 cases, 13 had recurrent strokes, and 45 had a first episode. The mean age of recurrent cases was 62±11 years versus 52±16 years in first-episode cases (p = 0.054), with a significantly higher proportion of patients aged ≥60 years in the recurrent group (69% vs. 31%, p = 0.02). Anatomically, atrial septal aneurysm was significantly more frequent in recurrent cases (92% vs. 41%, p 0.01), as was the presence of a long tunnel (100% vs. 45%, p 0.01). On the other hand, there were no significant differences in the presence of large RL shunt (64% vs. 54 %, p=0.56) and eustachian valve and/or chiari network (46% vs. 30%, p 0.21). RoPE scores were significantly lower in recurrent cases (4.3±0.5 vs. 5.8±0.3, P = 0.01), and no recurrent stroke patients had a RoPE score ≥7 (0% vs. 40%, P 0.01). Additionally, no recurrent stroke patients had undergone bubble contrast testing to detect the presence of PFO at the time of their first stroke. Conclusion Atrial septal aneurysms and a long tunnel were significant risk factors for recurrent strokes in PFO patients. Despite a RoPE score below 7, PFO-related stroke remains a concern. While RoPE score and age are key considerations for PFO closure, careful evaluation, including bubble contrast studies and assessment of high-risk anatomical features, is necessary for selecting appropriate candidates, particularly among older individuals with recurrent events.
Murakami et al. (2025) studied this question.