{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T05:10:57Z","timestamp":1778217057508,"version":"3.51.4"},"reference-count":24,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T00:00:00Z","timestamp":1778198400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Indications for patent foramen ovale (PFO) closure after ischemic stroke are primarily guided by the Risk of Paradoxical Embolism (RoPE) score and the PFO-associated Stroke Causal Likelihood Classification (PASCAL). Their application in routine care, however, is not well characterized. This study describes real-world management of patients with PFO presenting with ischemic stroke or transient ischemic attack (TIA). TIA cases were included to reflect clinical practice but are interpreted descriptively, as PFO closure is not guideline-supported after TIA alone. As a secondary aim, the \u201cAge, Stroke Severity (NIHSS &amp;gt;5) to Find AF\u201d (AS5F) score was explored for atrial fibrillation (AF) risk assessment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This retrospective single-center study included consecutive patients with ischemic stroke or TIA and PFO treated at the University Medical Centre Mainz (2015\u20132022). TIA was defined clinically by symptom resolution within 24\u202fh due to inconsistent MRI availability. Follow-up was performed via standardized telephone interviews \u226512\u202fmonths after the index event. Subgroup analyses compared patients by PFO closure status, AF diagnosis, recurrent ischemic events, and age \u226560\u202fyears.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 188 patients, 62 underwent PFO closure. These patients were younger, had fewer cardiovascular risk factors, and more often exhibited embolic PFO features (PASCAL). The RoPE score was higher in the closure group (6.0\u202f\u00b1\u202f1.7 vs. 4.1\u202f\u00b1\u202f1.5;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f&amp;lt;\u202f0.001). The AS5F score was lower in closure patients but higher in those with AF (p\u202f&amp;lt;\u202f0.001). In patients \u226560\u202fyears, higher AS5F scores were associated with AF (cut-off 3.8;\n                      <jats:italic>p<\/jats:italic>\n                      \u202f=\u202f0.026). Despite greater comorbidity, over half of patients with recurrent events remained classified as cryptogenic.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>These findings reflect real-world decision-making in PFO-associated stroke and highlight limitations of score-based approaches. While RoPE and PASCAL remain central, structured AF risk assessment may provide additional value, particularly in older patients. The high rate of cryptogenic recurrence suggests that the role of PFO may be underestimated in clinical practice. Given the moderate sample size, especially in elderly patients, these results should be considered exploratory and hypothesis-generating.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fneur.2026.1792925","type":"journal-article","created":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T04:42:27Z","timestamp":1778215347000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["PFO closure in ischemic stroke: insights from a single-center real-world cohort"],"prefix":"10.3389","volume":"17","author":[{"given":"Felix","family":"M\u00fcller","sequence":"first","affiliation":[{"name":"Department of Neurology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arda","family":"Civelek","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Luis","family":"Weitbrecht","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lukas","family":"Badura","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kai Helge","family":"Schmidt","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Florian","family":"Schlotter","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Philipp","family":"Lurz","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stavros V.","family":"Konstantinides","sequence":"additional","affiliation":[{"name":"Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]},{"name":"Department of Cardiology, Democritus University of Thrace","place":["Alexandroupolis, Greece"]},{"name":"Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg","place":["Heidelberg, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Karsten","family":"Keller","sequence":"additional","affiliation":[{"name":"Department of Cardiology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]},{"name":"Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]},{"name":"German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Klaus","family":"Gr\u00f6schel","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marianne","family":"Hahn","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Timo","family":"Uphaus","sequence":"additional","affiliation":[{"name":"Department of Neurology, University Medical Center of the Johannes Gutenberg-University","place":["Mainz, Germany"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,8]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1016\/S0025-6196(12)60336-X","article-title":"Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts","volume":"59","author":"Hagen","year":"1984","journal-title":"Mayo Clin Proc"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"135","DOI":"10.1093\/qjmed\/os-23.90.135","article-title":"Paradoxical Embolism","volume":"23","author":"Thompson","year":"1930","journal-title":"QJM Int. J. Med"},{"key":"ref3","volume-title":"Bev\u00f6lkerung am 1. Januar nach Altersgruppe und Geschlecht","year":"2025"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"e391","DOI":"10.1016\/j.lpm.2016.10.003","article-title":"Epidemiology of stroke in Europe and trends for the 21st century","volume":"45","author":"B\u00e9jot","year":"2016","journal-title":"Presse Med"},{"key":"ref5","year":"2024"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"1983","DOI":"10.1212\/WNL.0b013e31821e5517","article-title":"Etiologic investigation of ischemic stroke in young adults","volume":"76","author":"Larrue","year":"2011","journal-title":"Neurology"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1148","DOI":"10.1056\/NEJM198805053181802","article-title":"Prevalence of patent foramen ovale in patients with stroke","volume":"318","author":"Lechat","year":"1988","journal-title":"N Engl J Med"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"2262","DOI":"10.1056\/NEJMoa071422","article-title":"Patent foramen ovale and cryptogenic stroke in older patients","volume":"357","author":"Handke","year":"2007","journal-title":"N Engl J Med"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1016\/S0140-6736(88)92944-3","article-title":"Patent foramen ovale in young stroke patients","volume":"332","author":"Webster","year":"1988","journal-title":"Lancet"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"2228","DOI":"10.1016\/j.jcin.2017.09.002","article-title":"Transcatheter patent foramen Ovale closure after cryptogenic stroke: an updated Meta-analysis of randomized trials","volume":"10","author":"Mojadidi","year":"2017","journal-title":"JACC Cardiovasc Interv"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"619","DOI":"10.1212\/WNL.0b013e3182a08d59","article-title":"An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke","volume":"81","author":"Kent","year":"2013","journal-title":"Neurology"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"878","DOI":"10.1001\/jamaneurol.2020.0458","article-title":"Proposal for updated nomenclature and classification of potential causative mechanism in patent foramen Ovale-associated stroke","volume":"77","author":"Elgendy","year":"2020","journal-title":"JAMA Neurol"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"2277","DOI":"10.1001\/jama.2021.20956","article-title":"Heterogeneity of treatment effects in an analysis of pooled individual patient data from randomized trials of device closure of patent foramen Ovale after stroke","volume":"326","author":"Kent","year":"2021","journal-title":"JAMA"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"221","DOI":"10.1212\/WNL.0000000000000589","article-title":"Recurrent stroke predictors differ in medically treated patients with pathogenic vs. other PFOs","volume":"83","author":"Thaler","year":"2014","journal-title":"Neurology"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"1643","DOI":"10.1161\/STROKEAHA.120.032453","article-title":"Embolic stroke of undetermined source and patent foramen Ovale: risk of paradoxical Embolism score validation and atrial fibrillation prediction","volume":"52","author":"Strambo","year":"2021","journal-title":"Stroke"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"526","DOI":"10.1177\/1747493016641967","article-title":"Embolic strokes of undetermined source: prevalence and patient features in the ESUS global registry","volume":"11","author":"Perera","year":"2016","journal-title":"Int J Stroke"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"1033","DOI":"10.1056\/NEJMoa1707404","article-title":"Patent foramen Ovale closure or antiplatelet therapy for cryptogenic stroke","volume":"377","author":"S\u00f8ndergaard","year":"2017","journal-title":"N Engl J Med"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"1541","DOI":"10.1161\/STROKEAHA.117.018153","article-title":"Patent foramen Ovale closure versus medical therapy for cryptogenic ischemic stroke: a topical review","volume":"49","author":"Saver","year":"2018","journal-title":"Stroke"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"e115","DOI":"10.1212\/WNL.0000000000006727","article-title":"Development and validation of a score to detect paroxysmal atrial fibrillation after stroke","volume":"92","author":"Uphaus","year":"2019","journal-title":"Neurology"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"800","DOI":"10.1177\/23969873241247978","article-title":"European stroke organisation (ESO) guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke","volume":"9","author":"Caso","year":"2024","journal-title":"Eur Stroke J"},{"key":"ref21","doi-asserted-by":"crossref","DOI":"10.25302\/04.2023.RS.SCOPE2019001","volume-title":"Evaluating Therapies to Prevent Future Stroke in Patients with Patent Foramen Ovale-Related Strokes \u2014 The SCOPE Study","author":"Kent","year":"2023"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"973","DOI":"10.1212\/WNL.28.10.973","article-title":"Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study","volume":"28","author":"Wolf","year":"1978","journal-title":"Neurology"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"1303","DOI":"10.1016\/j.jcin.2025.03.034","article-title":"PFO device closure in patients 60 years of age with ischemic stroke: results from U.S","volume":"18","author":"Satpathy","year":"2025","journal-title":"Medicare Beneficiaries JACC Cardiovasc Interv"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1177\/17474930241281120","article-title":"Recurrent ischemic stroke\/transient ischemic attack after patent foramen ovale closure: a cohort study","volume":"20","author":"S\u00f8rensen","year":"2025","journal-title":"Int J Stroke"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1792925\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T04:42:38Z","timestamp":1778215358000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1792925\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,8]]},"references-count":24,"alternative-id":["10.3389\/fneur.2026.1792925"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2026.1792925","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,8]]},"article-number":"1792925"}}