Introduction: Patent foramen ovale (PFO) is a com-mon abnormality affecting between 20% and 34% of the adult population. For most people it is a benign fin-ding; in some the PFO is associated with paradoxical embolism and stroke.

Methods: 41 year old patient, non smoker, no previ-ous medical history, no medication, was admitted, one month ago, for sudden onset of slurred speech, followed by left-side hemiplegia an alterated mental status. Angio CT and MRI demonstrated ischemic stroke with thrombotic occlusion of the right middle cerebral artery. Thrombolysis treatment (alteplase) was administrated with good results. Favorable evolution with progressively good motor recovery.

Results: Initial investigations for detection the cause of the cryptogenic stroke revealed no evidence of atrial fibrillation (72 hours Holter monitorization) or signi-ficant plaque disease. Transthoracic echocardiography excluded intracardiac thrombus or other abnormalities associated with cardioembolization. Further tests with transthoracic, bubble contrast and transoesophageal echocardiogram all indicated the presence of tunnel-shaped PFO up to 10 mm length and 7 mm right atrium opening. Lower limb venous Doppler ultrasound re-vealed active right peroneal veins thrombosis. In the presence of unprovoked deep vein thorombosis, cryp-togenic stroke and PFO, thrombophilia screening was performed. The bood tests revealed protein C deficien-cy and MTHFR heterozygous mutation. The anticoa-gulantion treatment with acenoucumarol was started. The RoPE (Risk of Paradoxical Embolism) score has been developed and validated as an assessment tool to determine the probability that a PFO is responsible for a cryptogenic stroke. The patient had a hight score 8/10 (hight probability). PFO closure is routinely performed as a day-case procedure. In our center is done under lo-cal anesthesia, with no sizing balloon. PFO long-tunnel shape have a higher risk for device embolization, the-refore a larger device must be used. With fluoroscopic and transthoracic echocardiography guidance a 30/30 Cocoon device was successfully implanted, no re-sidual shunt. Because of the thrombophilia the acenou-cumarol must be continued life-long, in addision with clopidogrel for 6 months.

Conclusions: T he randomised controlled trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. The role of PFO closure in patients with venous thromboembolism and/or trombophilia must be individualized. Anticoagulation therapy may be adequate, although an individualized assessment needs to consider the added protection of PFO closure from the devastating impact of recurrent stroke and the frequent lapses in anticoagulation therapy because of noncompliance or planned interrupted therapy.