Decision dilemmas and insights in secondary prevention of ischemic stroke: a case report of an elderly patient with hereditary thrombophilia and high-risk patent foramen ovale
4 affiliations
- 1Institute of Basic Experiments, Zhejiang Academy of Traditional Chinese Medicine, Hangzhou, China
- 2Department of Cardiology, Tongde Hospital of Zhejiang Province, Hangzhou, China
- 3Department of Neurology, Tongde Hospital of Zhejiang Province, Hangzhou, China
- 4Department of Critical Care Units, Tongde Hospital of Zhejiang Province, Hangzhou, China
Abstract
This study reports the case of a 74-year-old female patient (aged 70 at the initial 2021 event) with hereditary thrombophilia and a patent foramen ovale (PFO) possessing high-risk anatomical features. The patient presented in December 2021 with pulmonary embolism and acute multiple cerebral infarctions due to PFO-associated paradoxical embolism. Genetic testing confirmed hereditary thrombophilia (plasminogen activator inhibitor-1, 4G/4G genotype). Despite standard anticoagulation, she developed recurrent thrombosis. Subsequent transesophageal echocardiography (May 2025) delineated the high-risk PFO anatomy. The Risk of Paradoxical Embolism (RoPE) score was 3, corresponding to a PFO‑attributable fraction of approximately 23%. This case illustrates a dual-risk mechanism for stroke: a persistent prothrombotic state coexisting with a definitive structural embolic pathway. The patient subsequently underwent percutaneous PFO closure. This case highlights the conflict between the need for individualized intervention based on dual high-risk mechanisms and the age-based recommendations of current guidelines (ESC 2023, AHA/ASA 2021). Anatomical assessment of the PFO enables a more precise estimation of stroke recurrence risk and the potential value of closure. As a causative therapy aimed at eliminating the structural embolic pathway, PFO closure may represent a reasonable interventional strategy in such carefully selected high-risk patients; however, its definitive net clinical benefit requires validation through prospective, large-scale trials.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12959-026-00905-1.
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BibTeX
@article{xue2026decision,
title = {{Decision dilemmas and insights in secondary prevention of ischemic stroke: a case report of an elderly patient with hereditary thrombophilia and high-risk patent foramen ovale}},
author = {Xiaomin Xue and Tianjie Zhang and Ziqiang Yu and Muhua Dai},
journal = {Thrombosis Journal},
year = {2026},
month = jul,
doi = {10.1186/s12959-026-00905-1},
url = {https://doi.org/10.1186/s12959-026-00905-1},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Decision dilemmas and insights in secondary prevention of ischemic stroke: a case report of an elderly patient with hereditary thrombophilia and high-risk patent foramen ovale
AU - Xiaomin Xue
AU - Tianjie Zhang
AU - Ziqiang Yu
AU - Muhua Dai
PY - 2026
DA - 2026/07/29
JO - Thrombosis Journal
DO - 10.1186/s12959-026-00905-1
UR - https://doi.org/10.1186/s12959-026-00905-1
AB - This study reports the case of a 74-year-old female patient (aged 70 at the initial 2021 event) with hereditary thrombophilia and a patent foramen ovale (PFO) possessing high-risk anatomical features. The patient presented in December 2021 with pulmonary embolism and acute multiple cerebral infarctions due to PFO-associated paradoxical embolism. Genetic testing confirmed hereditary thrombophilia (plasminogen activator inhibitor-1, 4G/4G genotype). Despite standard anticoagulation, she developed recurrent thrombosis. Subsequent transesophageal echocardiography (May 2025) delineated the high-risk PFO anatomy. The Risk of Paradoxical Embolism (RoPE) score was 3, corresponding to a PFO‑attributable fraction of approximately 23%. This case illustrates a dual-risk mechanism for stroke: a persistent prothrombotic state coexisting with a definitive structural embolic pathway. The patient subsequently underwent percutaneous PFO closure. This case highlights the conflict between the need for individualized intervention based on dual high-risk mechanisms and the age-based recommendations of current guidelines (ESC 2023, AHA/ASA 2021). Anatomical assessment of the PFO enables a more precise estimation of stroke recurrence risk and the potential value of closure. As a causative therapy aimed at eliminating the structural embolic pathway, PFO closure may represent a reasonable interventional strategy in such carefully selected high-risk patients; however, its definitive net clinical benefit requires validation through prospective, large-scale trials. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12959-026-00905-1.
SN - 1477-9560
ER -