Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology

Neurology. 2020 May 19;94(20):876-885. doi: 10.1212/WNL.0000000000009443. Epub 2020 Apr 29.


Objective: To update the 2016 American Academy of Neurology (AAN) practice advisory for patients with stroke and patent foramen ovale (PFO).

Methods: The guideline panel followed the AAN 2017 guideline development process to systematically review studies published through December 2017 and formulate recommendations.

Major recommendations: In patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke (level B). In patients with a higher risk alternative mechanism of stroke identified, clinicians should not routinely recommend PFO closure (level B). Clinicians should counsel patients that having a PFO is common; that it occurs in about 1 in 4 adults in the general population; that it is difficult to determine with certainty whether their PFO caused their stroke; and that PFO closure probably reduces recurrent stroke risk in select patients (level B). In patients younger than 60 years with a PFO and embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (absolute recurrent stroke risk reduction of 3.4% at 5 years) and risks (periprocedural complication rate of 3.9% and increased absolute rate of non-periprocedural atrial fibrillation of 0.33% per year) (level C). In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend an antiplatelet medication such as aspirin or anticoagulation (level C).

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aspirin / therapeutic use*
  • Atrial Fibrillation / complications
  • Foramen Ovale, Patent / complications
  • Foramen Ovale, Patent / prevention & control*
  • Humans
  • Platelet Aggregation Inhibitors / therapeutic use
  • Risk Assessment
  • Risk Factors
  • Secondary Prevention*
  • Septal Occluder Device / adverse effects
  • Stroke / epidemiology
  • Stroke / prevention & control*
  • United States


  • Platelet Aggregation Inhibitors
  • Aspirin