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Background: The assessment of cranial foramina is an important part of the objective diagnostic and therapeutic study relevant to pathologies involving structures of the skull base. The study of the foramen ovale not only holds significance for anatomical development but also bears profound surgical importance, such as in trigeminal neuralgia, and diagnostic importance in tumors and various types of epilepsy. It becomes relevant in fine-needle aspiration techniques in perineural tumor procedures, for electroencephalographic analysis in seizures, and therapeutic procedures such as percutaneous trigeminal rhizotomy for trigeminal neuralgia. Methods: A cross-sectional study at the Department of Neurosurgery, Specialties Hospital, La Raza National Medical Center, Mexico City, involved 70 patients aged >18 years who underwent a single skull computed tomography scan between July 2023 and March 2024. Patients with sufficient scan quality and optimal visualization of skull base foramina were included in the study. Measurements of tomographic images were taken using Inobitec's DICOM file viewer. Data analysis in Microsoft Excel yielded mean, standard deviation, and 95% confidence interval (CI) for morphometric parameters of the foramen ovale. Results: Analysis of tomographies from 70 patients revealed a total of 140 foramen ovale, evenly split between 25 males (35.7%) and 45 females (64.3%). The measurements for the maximum anteroposterior diameter, transverse diameter, and surface area of all foramina were as follows: 6.61 ± 0.25 mm (95% CI), 3.97 ± 0.21 mm (95% CI), and 20.84 ± 1.58 mm2 (95% CI), respectively. Specific measurements for the right and left sides were obtained: for the right side, 6.59 ± 0.26 mm (95% CI) and 3.89 ± 0.21 mm (95% CI) for the maximum anteroposterior and transverse diameters, respectively, and 20.38 ± 1.62 mm2 (95% CI) for the surface area. For the left side, the measurements were 6.63 ± 0.24 mm (95% CI), 4.05 ± 0.21 mm (95% CI), and 21.31 ± 1.55 mm2 (95% CI) for the maximum anteroposterior diameter, transverse diameter, and surface area, respectively. The maximum and minimum dimensions for anteroposterior and transverse diameters were 10.67 mm, 4.41 mm, 7.09 mm and 2.36 mm, respectively, with a corresponding range for the surface area of 10.16 mm2-44.13 mm2. The average minimum distance between the foramen ovale and the foramen spinosum was 2.32 ± 0.24 mm (95% CI). In males, the average size of the foramen ovale was 23.66 ± 1.61, which was 22% larger than the average size in females (19.28 ± 1.45) (P = 0.0001). Conclusion: The foramen ovale is one of the main anatomical structures of the skull base, and besides that, it is complex and not directly accessible for clinical evaluation, useful information can be obtained through morphometric analysis. The present study provides specific anatomical data with morphological patterns to increase the understanding of the characteristics of the foramen ovale in the Mexican population. These are intended to be helpful in the pursuit of acknowledging the morphometrics and thus being able to plan neurosurgical procedures in the middle cranial fossa.

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Introducción. La embolia paradójica es un evento trombótico originado en la circulación venosa, que se manifiesta como embolismo arterial por medio de un defecto anatómico a nivel cardíaco o pulmonar. Se asocia principalmente a eventos cerebrovasculares, aunque se han encontrado casos de infarto agudo de miocardio, infarto renal y otros eventos isquémicos. Caso clínico. Paciente de 47 años, quien consultó por cuadro de dolor abdominal, que requirió manejo quirúrgico de urgencia, donde identificaron isquemia intestinal importante. Los estudios adicionales hallaron déficit de proteína S y persistencia de foramen oval permeable. Resultados. La presencia de trombosis arterial se conoce como trombosis de sitios inusuales y requiere de estudios para descartar trombofilias asociadas u otros estados protrombóticos. El déficit de proteína S es una trombofilia infrecuente, la cual se asocia en la vida adulta a eventos trombóticos de origen venoso. En presencia de defectos anatómicos, como un foramen oval permeable, puede progresar a embolia arterial, configurando un cuadro de embolismo paradójico. La estratificación de estos pacientes requiere imágenes que demuestran el defecto mencionado, así como el posible origen de los émbolos. El manejo se basa en anticoagulación plena, manejo de soporte, resolver las manifestaciones trombóticas existentes y un cierre temprano del defecto anatómico. Conclusiones. El embolismo paradójico debe sospecharse en caso de trombosis de sitios inusuales. Requiere de un estudio exhaustivo con imágenes y su manejo debe basarse en anticoagulación y cierre del defecto.

Introduction. Paradoxical embolism is a thrombotic event originating in the venous circulation, which manifests as arterial embolism through an anatomical cardiac or pulmonary defect. It is mainly associated with stroke, also presenting as acute myocardial infarction, renal infarction, and other ischemic events. Clinical case. A 47-year-old patient was admitted due to abdominal pain, which required emergency surgical management, finding significant intestinal ischemia. Additional studies found protein S deficiency and evidence of a patent foramen ovale. Discussion. Arterial thrombosis is known as unusual thrombosis; this situation requires to rule out associated thrombophilia or other prothrombotic diseases. Protein S deficiency is a rare thrombophilia, which in adults causes venous thrombosis. In the presence of anatomical defects, such as a patent foramen ovale, it can progress to arterial embolism, presenting a picture of paradoxical embolism. The study work of these patients requires imaging that demonstrates the aforementioned defect, as well as the possible origin of the emboli. Management is based on full anticoagulation, treatment of existing thrombotic manifestations, and management of the anatomical defect. Conclusions. Paradoxical embolism should be suspected in case of unusual thrombosis. It requires exhaustive studies based on imaging, and management should consist of anticoagulation and closure of the defect.

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RESUMEN La embolia cerebral paradójica siempre requiere la presencia de foramen oval; en nuestro caso, este evento sucedió por un fenómeno temporal, el cual fue la sobrecarga aguda de las cavidades derechas y la apertura del foramen oval debido al aumento de presiones como consecuencia de un tromboembolismo pulmonar masivo. Luego de una artroscopía, nuestra paciente presentó pérdida del campo visual y disnea, esta última progresiva, hasta llegar a la ventilación mecánica y shock obstructivo grave. Se realizó una angiotomografía, la cual evidenció un trombo obstructivo en la arterial pulmonar derecha; la paciente fue trombolizada con éxito y fue dada de alta de la unidad de cuidados intensivos después de 45 días. Finalmente se le diagnosticó una deficiencia de proteína C y se inició anticoagulación de manera permanente. La presencia de déficit motor y disnea en una paciente post-cirugía de rodilla, debe hacer sospechar de una tromboembolia pulmonar, la trombólisis sigue siendo el tratamiento de elección, su indicación debe ser precoz.

ABSTRACT Paradoxical cerebral embolism always requires the presence of a patent foramen ovale (PFO); in our case, this event occurred due to a transient phenomenon, which was the acute overload of the right heart chambers and the opening of the PFO due to increased pressures as a consequence of massive pulmonary thromboembolism. After undergoing arthroscopy, this patient presented with visual field loss and progressive dyspnea, ultimately leading to mechanical ventilation and severe obstructive shock. An angiotomography was performed, revealing an obstructive thrombus in the right pulmonary artery. The patient successfully underwent thrombolysis, and she was discharged from the intensive care unit after 45 days. Ultimately, protein C deficiency was diagnosed, and permanent anticoagulation was initiated. The presence of motor deficit and dyspnea in a post-knee surgery patient should raise suspicion of pulmonary thromboembolism. Thrombolysis remains the treatment of choice, and it should be timely prescribed and performed.

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Resumo Fundamento O forame oval permanece pérvio em cerca de 25% da população adulta. Na vida adulta, trombos se formam na circulação venosa e podem atravessar o septo interatrial e desencadear um acidente vascular cerebral isquêmico - fenômeno chamado de embolia paradoxal. O tratamento pode ser realizado através do fechamento percutâneo do forame oval patente (FOP), porém ainda é pouco realizado no Brasil por não estar disponível na rede pública. Objetivos Avaliar a reprodutibilidade dos resultados dos ensaios clínicos em estudos de vida real devido ao escasso número de registros publicados sobre o tema. Métodos Este estudo é uma coorte retrospectiva onde foram incluídos 121 pacientes submetidos ao fechamento percutâneo do FOP para profilaxia secundária de acidente vascular cerebral isquêmico entre janeiro de 2012 e junho de 2022. Resultados Observamos idade média de 50,3 anos e a maioria do sexo feminino. O shunt interatrial grave foi observado em 82,6% e a presença de aneurisma de septo atrial em 84,2%. Após 6 meses do procedimento, nenhum paciente permaneceu com shunt residual. Não houve complicações hemorrágicas ou vasculares graves. A recidiva de novo evento cerebrovascular isquêmico ocorreu em 1,6% dos pacientes. Conclusão Observamos uma recidiva de novos eventos neurológicos isquêmicos muito baixa e ausência de complicações graves associadas ao procedimento.

Abstract Background The foramen ovale remains patent in about 25% of the adult population. In adult life, thrombi form in the venous circulation and can cross the interatrial septum and trigger an ischemic stroke - called paradoxical embolism. The treatment can be performed through percutaneous closure of the patent foramen ovale (PFO), but still rarely performed in Brazil because it is not available in the public health care. Objectives To evaluate the reproducibility of clinical trial results in real-life studies due to the low number of records published about the topic. Methods This study is a retrospective cohort study including 121 patients who underwent percutaneous PFO closure for secondary prophylaxis of ischemic stroke between January 2012 and June 2022. Results We observed a mean age of 50.3 years and most females . Severe interatrial shunt was observed in 82.6% and the presence of atrial septal aneurysm in 84.2%. After 6 months of the procedure, no patient still had a residual shunt. There were no serious bleeding or vascular complications. Recurrence of a new cerebrovascular event occurred in 1.6% of patients. Conclusion We observed a low recurrence of new ischemic neurological events and lack major complications related to the procedure.

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La migraña es una enfermedad que se ha visto asociada a defectos septales auriculares y a su cierre percutáneo, estipulándose en la literatura que sería una rara complicación, pero la evidencia al respecto es escasa. Se realizó una revisión narrativa sobre definiciones, epidemiología, fisiopatología y tratamiento de la migraña y de la entidad migraña poscierre percutáneo de defectos del septum auricular, incluyendo trabajos observacionales (retrospectivos, prospectivos), estudios randomizados, reportes de casos, artículos de revisión y metaanálisis existentes en PubMed y Cochrane, para aportar al conocimiento de esta entidad.

Migraine is a disease that has been associated with atrial septal defects and its percutaneous closure, stipulating in the literature that it would be a rare complication, but evidence is scarce. A narrative review was conducted on definitions, epidemiology, pathophysiology and treatment of migraine and the migraine entity after percutaneous closure of atrial septum defects, including observational studies (retrospective, prospective), randomized studies, case reports, review articles and meta-analyses existing in PubMed and Cochrane, to contribute to the knowledge of this entity.

A enxaqueca é uma doença que tem sido associada a defeitos do septo atrial e seu fechamento percutâneo, estipulando na literatura que seria uma complicação rara, mas as evidências são escassas. Foi realizada uma revisão narrativa sobre definições, epidemiologia, fisiopatologia e tratamento da enxaqueca e da entidade migranosa após fechamento percutâneo de defeitos do septo atrial, incluindo estudos observacionais (retrospectivos, prospectivos), estudos randomizados, relatos de caso, artigos de revisão e metanálises existentes no PubMed e Cochrane, para contribuir com o conhecimento dessa entidade.

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Abstract Platypnea-orthodeoxia syndrome (POS) is a rare condition of positional hypoxemia and dyspnea. The following is a case of hypoxemia for no obvious reason in the perioperative scenario. A 70-year-old male patient was submitted to a radical prostatectomy. On several occasions after anesthetic induction, peripheral oxygen saturation decreased without any understandable cause. In the postanesthesia care unit, severe hypoxemia occurred in the upright position, oddly correcting with recumbency. An echocardiography showed a right-to-left intracardiac shunt through a patent foramen ovale with no pulmonary hypertension, establishing POS. Achieving this diagnosis required a broad workup with a high degree of suspicion.

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SUMMARY: For the treatment of trigeminal neuralgia, the foramen ovale is reached by entering the cheek with a needle. Thermocoagulation is performed with balloon compression, administration of alcohol or radiofrequency. Apart from the classical method, it is theoretically possible to reach the foramen ovale through the mouth with the anterior approach. In our study, it was aimed to examine horizontally and vertically the angular values that must be given to the needle to reach the foramen ovale in the anterior approach. Three landmark points were determined on both right and left sides of 25 dry skulls. A rod was inserted starting from these landmark points and passing through the center of the foramen ovale. The vertical and horizontal angular values of this bar were measured. For each foramen ovale, 3 vertical angles, 3 horizontal angles and 4 distance measurements were made. There was a significant difference between the right and left sides in terms of horizontal angular values. Average values of horizontal angles (in degrees); on the right, 7.29 for H1, 12.15 for H2, 32.29 for H3; 1.26 for H1, 9.46 for H2, and 30.56 for H3 on the left side (p<0.005). The angle value was measured as 0 or negative value in 5 (20 %) of the H1 angle measurements made on the right side and 14 (56 %) on the left side. The H2 angle value was found to be smaller than the H1 angle in the skull 2 (8 %) on the right and 3 (12 %) on the left. There was no difference between the right and left sides in terms of vertical angular values. A significant difference was found between the right and left sides in the D1, D2, D4 distances (p<0.005). Six important anatomical features affecting angular values were encountered.

Para el tratamiento de la neuralgia del trigémino, se alcanza el foramen oval introduciendo una aguja en la mejilla. La termocoagulación se realiza con compresión con balón, administración de alcohol o radiofrecuencia. Aparte del método clásico, en teoría es posible alcanzar el foramen oval a través de la cavidad oral mediante el abordaje anterior. En nuestro estudio se tuvo como objetivo examinar horizontal y verticalmente los valores angulares que se deben dar a la aguja para alcanzar el foramen oval en el abordaje anterior. Se determinaron tres puntos de referencia en los lados derecho e izquierdo de 25 cráneos secos. Se insertó una varilla comenzando desde estos puntos de referencia y pasando por el centro del foramen oval. Se midieron los valores angulares verticales y horizontales de esta barra. Para cada foramen oval se realizaron mediciones de 3 ángulos verticales, 3 ángulos horizontales y 4 distancias. Hubo una diferencia significativa entre los lados derecho e izquierdo en términos de valores angulares horizontales. Valores medios de ángulos horizontales (en grados); a la derecha, 7,29 para H1, 12,15 para H2, 32,29 para H3; 1,26 para H1, 9,46 para H2 y 30,56 para H3 en el lado izquierdo (p<0,005). El valor del ángulo se midió como 0 o valor negativo en 5 (20 %) de las mediciones del ángulo H1 realizadas en el lado derecho y 14 (56 %) en el lado izquierdo. Se encontró que el valor del ángulo H2 era menor que el ángulo H1 en el cráneo 2 (8 %) a la derecha y 3 (12 %) a la izquierda. No hubo diferencia entre los lados derecho e izquierdo en términos de valores angulares verticales. Se encontró diferencia significativa entre el lado derecho e izquierdo en las distancias D1, D2, D4 (p<0,005). Se encontraron seis características anatómicas importantes que afectan los valores angulares.

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Introduction: patent foramen ovale (PFO) has been associated with systemic embolic events, and evidence in favor of its closure is increasing. Our objective is to describe the main clinical outcomes and complications of percutaneous closure of patent foramen ovale. Materials and methods: patients who underwent percutaneous PFO closure from January 1, 2016, through September 1, 2021, were recorded retrospectively. Immediate outcomes (<72 hours), and early and late-onset clinical outcomes were evaluated. In-hospital and follow-up mortality were evaluated through medical chart reviews or telephone calls. Results: forty patients who underwent percutaneous PFO closure were included. There was a mean follow up of 2.3 years, the mean age was 43 ± 13.6 years, 7% were over 60 years old, 72.5% were women, 25% were hypertensive, 20% had diabetes, and 10% had a history of migraines. The mean RoPE score was 6, and 50% had a score greater than 7. Out of all the cases, three (7.5%) had serious adverse events and four had immediate complications. During follow-up, 2.5% had early-onset events consisting of atrial fibrillation and 2.5% had late-onset events due to CVA recurrence. There were no deaths from neurological causes and we reported a 100% survival. Discussion: From our experience, we highlight a low percentage of serious adverse events, and a low number of immediate, early and late-onset events, with a 100% survival, showing excellent results for percutaneous PFO closure. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2585).

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Abstract A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Resumen Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

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A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

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This case report is a multimodal analysis of a pregnant patient with branch retinal artery occlusion (BRAO) associated to patent foramen ovale (PFO). A 28-year-old woman presented at the clinic 20 h after an acute, painless black spot appearance in the inferior temporal visual field of the right eye (OD). At that time, she was 18 weeks pregnant and had no report of complications in her previous pregnancy. Best-corrected visual acuity was 1.0 in both eyes. Color fundus photo, perimetry, and OCT angiography were required. The results clearly showed an embolus in the superior nasal retinal arteriole, associated with a pallor in the distal retina. Patient was referred to a cardiologist and a transcranial Doppler with contrast indicated a right-to-left intracardiac shunt, confirmed by the presence of a PFO at the transesophageal echocardiography. Thrombophilic conditions were excluded. Enoxaparin 1 mg/kg was started and kept until the delivery. Now, a PFO surgical closure is on schedule. This case highlights the noteworthiness of considering PFO as a source of embolism for BRAO in young patients, the capability of OCTA as a dye-free method for use in pregnancy and emphasizes the importance of systemic evaluation in patients with BRAO.

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To determine reference values for the foramen ovale (FO) area of fetal hearts by three-dimensional (3D) ultrasound using spatio-temporal image correlation (STIC) method in the rendering mode, as well as applicability in fetuses with congenital heart disease (CHD). A retrospective and prospective study was performed of 242 normal fetuses and 36 fetuses with CHD between 20 and 33 + 6 weeks of gestation. The FO area was determined in the four-chamber view with manual delineation. To determine the reference curve of the FO area as a function of gestational age (GA), a linear regression model was utilized with an adjusted coefficient of determination (R2). For intra- and interobserver reproducibility calculations, the concordance correlation coefficient (CCC) was used. The mean ± standard deviation (SD) of the FO measurement area was 21.2 ± 1.8 and 48.1 ± 1.9 mm2 at 20 and 33 weeks' gestation, respectively. A linear correlation was observed between the FO area and GA (1.924*GA - 17.95; R2 = 0.91). Good intra- (CCC = 0.97) and interobserver (CCC = 0.94) agreement was observed for the FO area measurement. The mean difference in FO area between normal and CHD fetuses was - 14.4 mm2 (p < 0.001). Reference values for the FO area of fetal hearts were determined by 3D ultrasound using STIC in the rendering mode. This method showed good intra- and interobserver reproducibility and could be used to assess different CHD types.

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Resumo A comunicação do septo atrial (CIA) representa, aproximadamente, de 6%-10% dos defeitos cardíacos congênitos, com incidência de 1 em 1.500 nascidos vivos.1 Forame oval patente (FOP) é mais comum e está presente em mais de 20%-25% dos adultos.2 Síndromes clínicas associadas a CIA e FOP são variáveis, com implicações abrangendo a medicina pediátrica e adulta, neurologia e cirurgia. O interesse adicional na anatomia do septo interatrial (SIA) aumentou substancialmente nas últimas duas décadas, com evolução simultânea dos procedimentos percutâneos envolvendo cardiopatia estrutural do lado esquerdo e procedimentos eletrofisiológicos. Idealmente, essas intervenções baseadas em cateter requerem rota direta para o átrio esquerdo (AE) através do SIA, necessitando completo entendimento de sua anatomia. Atualmente, tecnologias de imagem sofisticadas e não invasivas como ecocardiografia transesofágica bidimensional (ETE 2D) e tridimensional (ETE 3D), ressonância cardíaca (RMC) e tomografia computadorizada (TC) passaram por um extraordinário desenvolvimento tecnológico, fornecendo detalhes anatômicos das estruturas cardíacas visualizadas em formato 2D e 3D e são essenciais para diagnóstico e tratamento de pacientes com doenças cardíacas. A avaliação da anatomia e anormalidades do SIA, portanto, requer abordagem padronizada e sistemática, integrando modalidades diagnósticas e fornecendo avaliação adequada e uniforme para terapias cirúrgicas e transcateter.

Abstract Atrial septal defects (ASD) account for approximately 6%-10% of congenital heart defects, with an incidence of 1 in 1,500 live births.1 Patent foramen ovale (PFO) is more common and is present in more than 20%-25% of adults.2 Clinical syndromes associated with ASD and PFO are variable, and their implications are targeted by pediatric and adult medicine, neurology, and surgery. Additional interest in the anatomy of the interatrial septum (IAS) has increased substantially over the last two decades. Additionally, percutaneous procedures involving left-sided structural heart disease and electrophysiological procedures have evolved considerably. Ideally, these catheter-based interventions require a direct route to the left atrium (LA) through the IAS, with a full understanding of its anatomy. Also, sophisticated and noninvasive imaging technologies such as two-dimensional transesophageal echocardiography (2D-TEE) and three-dimensional transesophageal echocardiography (3D-TEE), cardiac magnetic resonance imaging (CMR), and computed tomography (CT) have evolved considerably, providing anatomical details of cardiac structures visualized in 2D and 3D format and being key for the diagnosis and treatment of patients with heart diseases. Therefore, assessing the anatomy of the IAS and any abnormalities requires a standardized and systematic approach, integrating diagnostic modalities and enabling adequate and consistent evaluation for both surgical and transcatheter therapies.

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Background: Despite enormous advances in the diagnosis and treatment of ischemic stroke over the past decades, the extent of "standard" investigation to define its causes is heterogeneous. Young patients often undergo a myriad of diagnostic tests in developed countries, but the cost-effectiveness of this approach is uncertain. Objectives: Our main goal was to compare the frequencies of ischemic stroke of undetermined and determined etiologies in young patients with "complete" or "incomplete" investigation according to either a stepwise or an extensive protocol. Methods: Data from 143 young patients with ischemic stroke were reviewed. For each patient, available data were assessed by means of a stepwise and an extensive protocol of investigation. We compared the frequencies of ischemic stroke of undetermined and determined etiology according to "complete" or "incomplete" investigation according to each protocol. Results: Completeness of investigation led to a significant increase in determination of stroke etiology when a stepwise approach but not an extensive protocol was applied. Conclusions: These results suggest that ordering an extensive workup to all young patients does not enhance the capability of determining causes of ischemic stroke. Evidence-based guidelines to define pathways of investigation and consensus about the interpretation of tests are deeply needed.

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Introdução: A possibilidade de shunt da direita para esquerda pelo forame oval é causa potencial de embolia paradoxal. A presença de forame oval entre os pacientes com acidente vascular cerebral isquêmico criptogênico em mais de 40% dos casos despertou interesse em avaliar o impacto de seu fechamento na redução de recidiva da doença. O estudo objetiva relatar a experiência de 20 anos com fechamento percutâneo de forame oval realizado por um único operador. Métodos: Foram submetidos a fechamento percutâneo de forame oval associado a shunt da direita para esquerda 527 pacientes com acidente vascular cerebral isquêmico. Resultados: O procedimento foi realizado com sucesso em todos os pacientes. A média da idade foi de 48 anos (9 a 72 anos), sendo 57% do sexo masculino. Foram implantadas prótese Amplatzer® em 295 pacientes (56%) e Occlutech® em 232 (44%). Não houve mortalidade, e ocorreram as seguintes complicações: hematoma no local da punção em três pacientes (0,6%); fístula arteriovenosa femoral em dois (0,4%) com resolução espontânea; tamponamento cardíaco em dois (0,4%) com resolução após punção e drenagem; arritmia supraventricular transitória em três (0,6%); cefaleia em 27 (5,1%); fibrilação atrial em dois (0,4%); shunt residual grande com necessidade de segunda prótese em dois pacientes (0,4%); recorrência de acidente vascular cerebral isquêmico em seguimento em 5 anos em quatro (0,8%) e hipersensibilidade ao níquel em uma paciente (0,2%). Conclusão: A oclusão de forame oval como prevenção de recorrência de acidente vascular cerebral isquêmico nessa série se mostrou segura, eficaz e com baixo índice de recidiva em 5 anos de seguimento.

Background: Left-to-right shunting via the foramen ovale is a potential cause of paradoxical embolism. The presence of patent foramen ovale in more than 40% of patients with idiopathic ischemic stroke has led to deeper investigation of the impact of its closure on decreasing stroke recurrence rates. This study describes 20 years of experience with percutaneous patent foramen ovale occlusion performed by a single operator. Methods: This sample comprised 527 patients with ischemic stroke submitted to percutaneous occlusion of patent foramen ovale associated to left-to- right shunting. Results: The procedure was successful in all cases. The mean age was 48 years (range of 9 to 72 years), and 57% were male. Amplatzer® and Occlutech® prostheses were implanted in 295 and 232 patients (56% and 44%, respectively). There were no deaths, and complications were as follows: hematoma at the puncture site (three patients, 0.6%), femoral arteriovenous fistula with spontaneous resolution (two patients, 0.4%), cardiac tamponade resolved after puncture and drainage (two patients, 0.4%), transient supraventricular arrhythmia (22 patients, 4.2%), headache (27 patients, 5.1%), atrial fibrillation (two patients, 0.4%), large residual shunt requiring a second prosthesis (two patients, 0.4%), recurrence of ischemic stroke within 5 years (four patients, 0.8%) and hypersensitivity to nickel (one patient, 0.2%). Conclusion: In this series, patent foramen ovale occlusion was a safe and effective alternative for prevention of recurrent ischemic stroke. Recurrence rates over the course of 5 years were low.