Abstract
To the Editor: Paradoxical embolism via right-to-left shunts (RLS) has rapidly evolved into an area of intense research in stroke and migraine. Increasing attention focuses on distinguishing anatomic features of a patent foramen ovale (PFO) visualized by transesophageal echocardiography (TEE) from functional aspects (ie, shunts) that allow clots to pass from venous to arterial circuits, thereby circumnavigating typical filtration in the lungs. TEE and transcranial Doppler (TCD) microbubble injection techniques may detect shunting at rest or with Valsalva maneuver to accentuate venous pressures, yet thromboemboli are rarely noted. Intense speculation, however, has centered on clot composition and potential response to fibrinolytics despite that only a few dozen clots causing strokes in humans have ever been analyzed. Kimura et al provide fascinating data demonstrating a link between RLS and dramatic response to fibrinolytics in acute stroke (OR, 5.9; 95% CI, 1.3 to …
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