This patient has features of a cryptogenic stroke and patent foramen ovale (PFO). Antiplatelet therapy, such as aspirin, is first-line therapy for patients with PFO and initial cryptogenic stroke. The foramen ovale usually closes within the first few weeks of life. In 25% to 30% of the population, the foramen ovale remains patent. This is usually an incidental finding.

Data are insufficient to recommend PFO device closure for secondary stroke prevention after a first stroke unless there are exceptional circumstances, such as oxygen desaturation from right-to-left shunt or thrombus trapped in the PFO, or for patients with recurrent cryptogenic stroke on warfarin therapy. Overall, the PFO device closure procedure is safe and short-term complications are rare; however, evidence of long-term follow-up and benefit is lacking. Randomized controlled studies have failed to demonstrate superiority of closure over antiplatelet therapy for secondary prevention after cryptogenic stroke. Uncertainty persists regarding the best management strategy because of limitations of current randomized controlled studies; therefore, a reasonable consideration is to encourage participation in one of the ongoing clinical trials.

Data are insufficient to support warfarin therapy for patients with PFO and initial cryptogenic stroke. Warfarin is the treatment of choice for patients with PFO and recurrent stroke or for patients with stroke and a documented hypercoagulable state.

Surgical PFO closure, including a minimally invasive approach, is another option for patients with PFO and recurrent cryptogenic stroke but the efficacy of surgical closure in these patients has been variable and randomized trials have not been performed.