A "hole" in the heart: How patent foramen ovale (PFO) can be a quiet contributor to unexplained stroke in young people

May 07, 2021 | Blogs

It's true that the older you get, the higher your risk of stroke increases.

But strokes can occur at any age, even if you're "young" (that is, someone younger than 60).

Often, strokes in the young are cryptogenic (unexplained), particularly in those who aren't at risk of the more common causes like high blood pressure or high cholesterol. This can sometimes lead to the discovery of rare, underlying conditions as contributing causes.

One rare contributor to unexplained stroke in young, generally healthy people is something we all had before we were born: patent foramen ovale, a "hole" in the heart.

Before a baby is born, before it takes its first breath, a hole (foramen ovale) exists in the wall between the left and right atria of the fetus. This hole allows blood to go around the lungs and flow from one side of the heart to the other until after the baby is born and the lungs are exposed to air. The hole closes in most everyone upon breathing for the first time after birth. In about 25% of people in the general American population, however, the hole fails to close, resulting in a patent foramen ovale, or PFO.

"This condition is considered a source for a clot to travel from the heart to the brain and cause stroke," says Richard S. Jung, M.D., a LifeBridge Health vascular neurologist and neurointerventional surgeon and director of the stroke program at The Sandra and Malcolm Berman Brain & Spine Institute.

Here is what's tricky about PFO, and how it can so sneakily contribute to stroke: you can have it and not know it, as it often doesn't cause symptoms or lead to complications, and there is no prescreening for the condition.

In fact, diagnosing the condition in general can be complicated. PFO can go undetected by a standard echocardiogram.

"A good way to test for it is an echocardiogram along with what we call a bubble study," Jung says. "Bubbles are injected into the vein, and those little microbubbles travel to the right side of the heart, and then during the echocardiogram, we see if any of the bubbles have moved quickly over to the left side of your heart, and that indicates the presence of a hole."

Jung adds: "Now, that's just the screening test. To confirm PFO, we have to do a more evasive echocardiogram, where we do something that's called a transesophageal echocardiogram (TEE)." (During a TEE, doctors take pictures of the patient's heart via an ultrasound device that's guided into the esophagus with a tube.)

One reason PFO screenings are not ordinarily recommended is that even if you have one, "that is not to predict that you're going to have a stroke or TIA" (transient ischemic attack), Jung says. But if you've had a case of unexplained stroke, you may want to ask your doctor about the possibility of screening for PFO if this has not already been investigated by a neurologist. Some clinical trials have suggested that young patients may benefit from surgical PFO closure.

"If you truly do have an unexplained or cryptogenic stroke, and you're young, and you have a PFO that's established, then it is recommended to have that PFO closed," Jung says. "We can close it with a minimally invasive procedure where a cardiologist will seal the hole with a device that kind of clamps on to each side of the heart chamber and becomes part of the heart wall. That is something that's relatively new."

PFO treatment isn't considered only in the case of a full-on stroke, which can cause irreversible brain damage. Even in the case of TIA-the temporary blockage of blood flow to the brain, essentially a stroke in progress-when the blockage resolves on its own without causing permanent damage, PFO closure is still recommended "because the risk of having a potentially disabling or fatal stroke is significant after having a TIA," Jung says.

PFO is one of many conditions treated by our multidisciplinary team of cardiovascular experts at LifeBridge Health. To learn more, visit lifebridgehealth.org/cardio. You can also visit lifebridgehealth.org/stroke to learn more about LifeBridge Health's award-winning stroke centers. For more about scheduling an appointment and all other services offered by LifeBridge Health, including specialty care and community events, please visit lifebridgehealth.org or call 410-601-WELL.