title: Patent foramen ovale and stroke in childhood: A systematic review of the literature.
abstract: BACKGROUND
  Stroke in association with a patent foramen ovale (PFO) may be due to paradoxical embolization via a right to left intracardiac shunt but the exact contribution of PFO to stroke or stroke recurrence in childhood remains unclear.
  
  
  METHODS
  To review the relationship of a PFO with stroke, and evaluate associated co-morbidities. An electronic database literature search of Pubmed, Cochrane and EMBASE was performed from January 2000-December 2014.
  
  
  RESULTS
  149 articles were retrieved, with overlap for diagnosis, management, treatment and outcome. 65 reports were utilized for the comprehensive review. Majority of childhood arterial ischemic stroke and transient ischemic attacks are associated with prothrombotic disorders or arteriopathy. Transthoracic echocardiography with a Valsalva maneuver is highly sensitive as a screening tool but may be falsely positive. Transthoracic echocardiography with color Doppler and a concurrent bubble contrast study are excellent for visualizing the atrial septum and PFO and identifying a right to left shunt. Current literature does not support PFO closure for cryptogenic stroke in young adults without an associated risk of thromboembolism.
  
  
  CONCLUSIONS
  High quality research in the pediatric population is lacking and most of the data is extrapolated from adults. Paradoxical embolism from a PFO as a cause of transient ischemic attack or stroke is a diagnosis of exclusion. PFO closure should be individualized based on significant shunting and risk factors such that maximum benefit is derived from the procedure. A young person with a PFO and stroke should be thoroughly investigated to rule out other etiologies.
authors.affiliation: Division of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada. Electronic address: rubeena.khan@medportal.ca.
authors.forename: Rubeena
authors.initials: R
authors.lastname: Khan
authors.affiliation: Division of Pediatric Hematology/Oncology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada. Electronic address: akchan@mcmaster.ca.
authors.forename: Anthony K
authors.initials: AK
authors.lastname: Chan
authors.affiliation: Division of Cardiology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada. Electronic address: mondalt@mcmaster.ca.
authors.forename: Tapas K
authors.initials: TK
authors.lastname: Mondal
authors.affiliation: Division of Neonatology, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada. Electronic address: paes@mcmaster.ca.
authors.forename: Bosco A
authors.initials: BA
authors.lastname: Paes
mesh_terms: D015897:Comorbidity; D019320:Embolism, Paradoxical / Q000150:complications* / Q000453:epidemiology; D054092:Foramen Ovale, Patent / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology; D006801:Humans; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000209:etiology*
keywords: Childhood; Diagnosis; Management; Patent foramen ovale; Stroke; Treatment