Acute Ischemic Stroke: Reperfusion, Supportive Care, and the Great Shift from Time-Based to Tissue-Based Management

In this episode of Hospital Medicine Unplugged, we demystify PFO workup and closure after ischemic stroke—who to test, who to close, and how to run a tight inpatient pathway.

We open with the right patients: nonlacunar, embolic-appearing infarcts in adults 18–60 with no better cause on initial workup. Everyone gets vascular imaging, inpatient rhythm monitoring, DVT screening, and risk-factor assessment before we even say “PFO.”

Then the diagnostics that matter: start with TTE + agitated-saline bubble, but plan for TEE with bubble to define shunt size, tunnel length, and atrial septal aneurysm (ASA)—the anatomy that changes decisions. Transcranial Doppler is your most sensitive shunt detector and pairs well with TEE. We highlight how to do Valsalva right (timing counts) and why a clean aortic arch and carotids are as important as the septum.

Causality tools you’ll actually use: RoPE score to gauge how likely the PFO caused the stroke, and PASCAL to combine RoPE with anatomy so you can label a PFO “likely,” “possible,” or “unlikely” culprit. High RoPE + large shunt/ASA = the sweet spot for closure benefit.

Next, the shortlist for closure:
• Age 18–60, nonlacunar stroke, no alternative mechanism, high-risk PFO anatomy (large shunt and/or ASA).
• >60 or vascular risk–heavy? Individualize—the bar is higher.
• Clear competing cause (AF, large-artery stenosis, true lacune)? Don’t close.

Therapy playbook: begin antiplatelet now; if DVT or another indication for anticoagulation exists, anticoagulate and rethink closure. When closing, we cover timing (typically 2–6 weeks post-stroke once stabilized), device expectations, and how to manage the peri-procedural window without pausing secondary prevention.

What closure buys you: lower recurrent ischemic stroke, especially with large shunts/ASA—at the cost of more peri-procedural atrial fibrillation (usually transient) and rare device issues. We give you the numbers you’ll quote on rounds and the talking points for shared decision-making.

Post-closure meds and follow-up: DAPT (aspirin + clopidogrel) for 1–3 months, then single antiplatelet long-term (device-specific nuance included). If a patient needs anticoagulation for another reason, use that instead of DAPT. Plan rhythm surveillance (30-day patch or equivalent) and echo to check for residual shunt.

Special situations you’ll actually encounter: concurrent DVT (paradoxical embolism), pregnancy, hypercoagulability, TIA without infarct (why evidence is thinner), migraine with aura (not an indication), and older adults with borderline benefit—how we navigate each.

We close with the system moves: a Heart–Brain pathway that bundles TEE/TCD orders, DVT ultrasound, extended rhythm monitoring, RoPE/PASCAL documentation, and default post-closure antithrombotics. Add a templated note for “PFO-likely” vs “PFO-unlikely” and track AF after closure as a quality metric.

Crisp, guideline-driven, and bedside-ready—everything your team needs to make smart, safe decisions about PFO diagnosis and closure in ischemic stroke.