Stroke

CLINICAL AND POPULATION SCIENCES

Frequency and Size of In Situ Thrombus Within

Patent Foramen Ovale
Chaowu Yan , PhD, MD; Hua Li, MD; Cheng Wang, PhD, MD; Hang Yu, MD; Tingting Guo, MD; Linyuan Wan, PhD, MD;
Pingcuo Yundan , MD; Lei Wang, PhD, MD; Wei Fang, PhD, MD

BACKGROUND: High-resolution optical coherence tomography can detect in situ thrombi within patent foramen ovale (PFO),
which can become a dangerous embolic source. This study aimed to investigate the frequency and size of in situ thrombus
within PFO using optical coherence tomography.

METHODS: The cross-sectional study was conducted at Fuwai Hospital (Beijing, China) between 2020 and 2021. From 528
consecutive patients with PFO, 117 (age, 34.33 [SD, 11.30] years) without known vascular risk factors were included;
according to PFO-related symptoms, they were divided into the stroke (n=43, including 5 patients with transient ischemic
attack), migraine (n=49) and asymptomatic (n=25) groups. Optical coherence tomography was used to evaluate in situ
thrombi and abnormal endocardium within PFO. Univariable analysis and a logistic model were used to evaluate the
association between stroke and in situ thrombus; age, sex, body mass index, and antithrombotic therapy were included
as covariates.

RESULTS: Antithrombotic therapy was used more frequently in the stroke group than in the migraine group (76.7%
versus 12.2%; P<0.001). In situ PFO thrombi were detected in 36 (83.7%), 28 (57.1%), and 0 (0.0%) patients from the
stroke, migraine, and asymptomatic groups, respectively (P<0.001). Between the stroke and migraine groups, there was
no significant difference in the median (interquartile range) thrombus number per patient (7 [3–12] versus 2 [0–10];
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P=0.199), maximum thrombus diameter (0.35 [0.20–0.46] versus 0.21 [0–0.68] mm; P=0.597), or total thrombus volume
(0.02 [0.01–0.05] versus 0.01 [0–0.05] mm3; P=0.386). Additionally, in situ thrombus was significantly associated with
stroke risk (odds ratio, 4.59 [95% CI, 1.26–16.69]). Abnormal endocardium within PFO occurred in patients with in situ
thrombi (71.9%) but not in those without. During optical coherence tomography examination, migraine occurred in 2
patients with in situ thrombi.

CONCLUSIONS: The frequency of in situ thrombus was extremely high in stroke and migraine groups, while none of the
asymptomatic individuals presented with an in situ thrombus. In situ thrombus formation may play a role in patients with PFO-
associated stroke or migraines and have therapeutic implications.

REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04686253.

GRAPHIC ABSTRACT: A graphic abstract is available for this article.

Key Words: foramen ovale ◼ ischemic stroke ◼ migraine disorders ◼ odds ratio ◼ optical coherence ◼ patent ◼ tomography

P
atent foramen ovale (PFO) is prevalent in the general
population with an autopsy incidence of 27.3%.1 It is
commonly accepted that PFO is associated with var-
ious pathological conditions, including ischemic stroke,
transient ischemic attack (TIA), migraines, and systemic
or coronary embolization.2–5 In particular, PFO is likely
responsible for ≈5% of all ischemic strokes and 10%
of all ischemic strokes in young and middle-aged adults,
respectively.5 In a clinical setting, identifying patients with
a high risk of PFO who may benefit from antithrombotic

Correspondence to: Chaowu Yan, PhD, MD, Department of Structural Heart Disease, Fuwai Hospital, 167 Beilishi Rd, Beijing 100037, China. Email chaowuyan@163.com
Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.122.041524.
For Sources of Funding and Disclosures, see page 1212.
© 2023 American Heart Association, Inc.
Stroke is available at www.ahajournals.org/journal/str

Stroke. 2023;54:1205–1213. DOI: 10.1161/STROKEAHA.122.041524 May 2023   1205

 Yan et al
CLINICAL AND POPULATION
Nonstandard Abbreviations and Acronyms
SCIENCES
IQR interquartile range
OCT optical coherence tomography
PFO patent foramen ovale
TIA transient ischemic attack
therapy or transcatheter closure is critical.6–19 However,
screening for cases of pathogenic PFO remains chal-
lenging because of the absence of verified predictors.
In addition to serving as a conduit for paradoxical emboli
originating from deep vein thrombosis, it has been hypoth-
esized that PFO might cause ischemic stroke via in situ
thrombus formation.2–5 In patients with PFO-associated
stroke, the reported prevalence of deep vein thrombosis
is approximately only 10%20–25; therefore, most embolic
sources remain undetermined. In selected patients with
PFO, antithrombotic therapy reduced not only the rate of
recurrent stroke but also the frequency and duration of
migraine headaches, suggesting a possible link between
thrombus formation and the 2 disorders.6–12
Our preliminary study suggested that high-resolution
optical coherence tomography (OCT) has the poten-
tial to detect microthrombi within the PFO, and in situ
thrombi have been previously identified in patients with
stroke or migraines.26 However, the frequency and size of
in situ thrombus within the PFO and consequent clinical
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implications remain unclear, especially in patients with
ischemic stroke/TIA or migraines. Detection of in situ
thrombus within the PFO might help distinguish patho-
genic PFO from incidental PFO.27
We hypothesized that (1) in situ thrombus within
the PFO might occur frequently in patients with PFO-
associated stroke or migraines and (2) in situ thrombus
might be rare in asymptomatic individuals. In this study,
OCT was used to evaluate the frequency and size of in
situ thrombus within the PFO in the stroke, migraine, and
asymptomatic groups.
METHODS
Study Design and Participants
This cross-sectional study was performed at Fuwai Hospital
(Beijing, China) between 2020 and 2021. Of the 528 consecu-
tive candidates with PFO, 131 (aged 16–65 years; medium-to-
large shunts) without known vascular risk factors were eligible
and underwent OCT examination for PFO. Based on PFO-related
symptoms, the patients were divided into the stroke (including
TIA alone), migraine, and asymptomatic groups. All patients were
thoroughly evaluated by cardiologists, neurologists, and imaging
specialists. In patients with neurological symptoms, the presence
of PFO was investigated after excluding other potential causes
and the symptoms were thought to be associated with ischemic
stroke, TIA, or migraine. In patients with stroke, acute infarction
1206   May 2023
In Situ Thrombus Within PFO
was confirmed through brain magnetic resonance imaging, and
antithrombotic therapy (antiplatelet/anticoagulation) was initi-
ated at the discretion of the treating physicians. All patients with
migraines were recruited in an outpatient setting and under-
went brain magnetic resonance imaging to exclude infarction;
migraines were diagnosed and classified by neurologists accord-
ing to the International Headache Society criteria.28 In asymptom-
atic individuals, PFO was an incidental finding on transthoracic
echocardiogram during routine examination, and further tests
were conducted in the presence of high-risk activities or high-risk
anatomical features related to PFO (Figures S1 and S2). The data
that support the findings of this study are available from the cor-
responding author upon reasonable request.
All patients underwent contrast-enhanced transcranial
Doppler preoperatively to determine the presence and severity
of a right-to-left shunt, and contrast transesophageal echocar-
diogram findings were available for 102 patients. For patients
who did not undergo transesophageal echocardiogram (refusal,
n=14; esophagitis, n=1) or had unclear transesophageal echo-
cardiogram results (n=7), pulmonary angiography was con-
ducted to exclude intrapulmonary shunts. In patients aged ≥45
years (n=24), computed tomography angiography was per-
formed to rule out coronary artery disease and carotid artery
lesions. To rule out atrial fibrillation, all patients were monitored
preoperatively with inpatient cardiac telemetry for at least 24
hours. Furthermore, deep venous thrombosis was ruled out
using venous Doppler ultrasonography.
All patients underwent right atrial angiography to opacify
the PFO, and OCT (Dragonfly Duo Imaging Catheter, LightLab
Imaging, Inc) was used to evaluate the PFO microstructure
during angiography while the patient performed the Valsalva
maneuver (Video S1; Supplemental Methods; Figures S3
through S11). The presence or absence of in situ thrombus
within the PFO was determined, and thrombus size was mea-
sured. Additionally, the PFO endocardium was assessed in
detail. During OCT examination, procedural complications were
recorded. Transcatheter closure was subsequently performed
in patients with ischemic stroke/TIA or migraine. After PFO
closure, right atrial angiography was performed to exclude
potential residual shunts. The inclusion and exclusion crite-
ria are described in Supplemental Methods. This study was
approved by the Ethics Committee of Fuwai Hospital, and writ-
ten informed consent was obtained from each patient.
Measurements of In Situ Thrombi and PFO
Figures S12 through S16 present the complete details of in
situ thrombi and PFO measurements. OCT images with visibility
in ≥3 quadrants were included in the analysis. The number of
in situ thrombi within the PFO were counted and classified into
small (1–10), medium (11–30), and large (>30); those >50 in
number or involving >2 quadrants and 1-mm length on OCT
images were defined as extremely large. The multiple-points
tool was used to draw the thrombus contour and determine
the maximum diameter and area of each thrombus. Next, the
thrombus volume was calculated by multiplying the thrombus
areas in each frame by the number of frames by 0.2 (length, 75)
mm/0.1 (length, 54) mm. For each patient, the total thrombus
volume was calculated based on the volume of each thrombus.
According to the visible OCT images, the endocardial bor-
ders were delineated semiautomatically within the PFO, and
Stroke. 2023;54:1205–1213. DOI: 10.1161/STROKEAHA.122.041524
 Yan et al
the areas within the endocardial contours were measured. For
OCT images with complete circumstances, endocardial con-
tours were determined using the lumen contour function. For
OCT images with incomplete circumstances, the disrupted
endocardial contours were edited manually and extended lines
were drawn from the disrupted borderlines (along the con-
tours) to form complete contours. Additionally, the endocardial
contours were manually corrected on OCT images with in situ
thrombi. In the analyzable segment, the distal area (left atrial
side), proximal area (right atrial side), and minimum area of the
PFO were determined within the endocardial contours. All OCT
images were analyzed by 2 independent cardiologist observ-
ers (blinded to the patients’ information) using an offline review
workstation (Offline Software E.5, Optis System; Abbott).
Definitions of In Situ Thrombus and Abnormal
Endocardium Within PFO
Within the PFO, an in situ thrombus was defined as the pres-
ence of an irregular mass ≥100 µm attached to the endocardial
surface (Figures S17 through S21).26 A free-floating thrombus
was defined as an elongated in situ thrombus with circumfer-
ential blood flow at the most distal aspect. In addition, abnormal
endocardium within the PFO was classified as (1) endocardial
surface irregularity: microspiculations <100 µm attached to the
endocardial surface; (2) endocardial surface discontinuity: a
localized defect on the endocardial surface; or (3) endocardial
signal-poor lesion: a localized region with low backscattering
adjacent to the endocardial surface (superficial lesion, limited
to intima; deep lesion, affecting the intima and subintima).
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Statistical Analysis
Categorical variables are expressed as percentages, and quan-
titative variables are expressed as mean (SD) or median (inter-
quartile range [IQR]). For the 3 groups, normally distributed
continuous variables, categorical variables, and non-normally
distributed or ordinal variables were tested using an analysis of
variance, the χ2 or Fisher test, and the Wilcoxon test, respec-
tively. The migraine and asymptomatic groups were combined
into the nonstroke group. The nonstroke group was used as
the reference group for evaluating the association of stroke
with in situ thrombus and its related indices using multivariable-
adjusted logistic models; age, sex, body mass index, and anti-
thrombotic therapy were used as covariates. Stratified analysis
was conducted among patients who underwent and did not
undergo antithrombotic therapy; intergroup differences were
tested by including an interaction term. Ten patients with in situ
thrombi were selected randomly, and Pearson correlation was
used to assess the intraobserver and interobserver reproduc-
ibility. A 2-sided P value <0.05 was considered statistically sig-
nificant. SAS, version 9.4 (SAS Institute, Cary, NC), was used
for all analyses.
RESULTS
Baseline Characteristics of the Participants
Of the 528 consecutive candidates with PFO, 131 were
eligible and 117 were included in the analysis (Fig-
ure 1). All PFOs were confirmed angiographically, with
Stroke. 2023;54:1205–1213. DOI: 10.1161/STROKEAHA.122.041524
In Situ Thrombus Within PFO
a right-to-left shunt present in all patients. Fourteen
CLINICAL AND POPULATION
patients were excluded postoperatively from the analy-
sis because of an insufficient image quality secondary
SCIENCES
to blood artifacts (n=12, involving >1 quadrant on the
cross-sectional OCT image; Figure S22) and unsuccess-
ful catheter passage across the atrial septum, despite
the presence of angiographic shunt and crossing of the
PFO with a guidewire (n=2; Figure S23).
The mean age of the 117 participants was 34.3 (SD,
11.3) years, and 75 (64.1%) were women (Table). In the
stroke group (n=43), 4 patients had a history of multiple
prior strokes, and 5 patients had a history of TIA alone.
The time elapsed between stroke/TIA and OCT was 3.4
(SD, 1.2) months, and the median (IQR) risk of paradoxi-
cal embolism score was high (9 [8–9]). In the migraine
group (n=49), the median history of migraine was 6 (IQR,
3–10) years; 27 patients (55.1%) experienced aura, and
7 experienced nausea and vomiting. In the asymptomatic
group (n=25), there were 19 individuals with high-risk
activities related to PFO and 15 with high-risk anatomi-
cal features (9 patients had both high-risk activities and
anatomical features, Supplemental Methods).
Antithrombotic therapy was administered more fre-
quently in the stroke group than in the migraine group
(76.7% versus 12.2%; P<0.001; Table S1). Antiplate-
let therapy was administered to 25 and 6 patients in
the stroke and migraine groups, respectively. Antico-
agulation therapy was administered to 8 patients in the
stroke group, who then underwent an OCT examination
thereafter. No intrapulmonary shunt was observed in
any of the patients who underwent pulmonary angiog-
raphy. Transcatheter PFO closure was performed suc-
cessfully in all patients with stroke/TIA or migraines.
After PFO closure, right atrial angiography revealed no
residual shunts (Figure S24).
In Situ Thrombi and Endocardial Abnormalities
Within PFO
In situ thrombi were detected in 36 patients in the stroke
group (83.7%), 28 in the migraine group (57.1%), and
none in the asymptomatic group (P<0.001; Figure 2).
The stroke and migraine groups did not differ signifi-
cantly in terms of the median (IQR) thrombus number
per patient (7 [3–12] versus 2 [0–10]; P=0.20), maxi-
mum thrombus diameter (0.35 [0.20–0.46] versus 0.21
[0–0.68] mm; P=0.60), and total thrombus volume (0.02
[0.01–0.05] versus 0.01 [0–0.05] mm3; P=0.39). In 5
patients with TIA in the stroke group, the median (IQR)
thrombus number per patient and total thrombus volume
was 7 (6–8) and 0.008 (0.007–0.018) mm3, respectively.
An extremely large number of thrombi were detected in
only 2 patients in the migraine group (Video S2). Fur-
thermore, in situ thrombus was associated with a history
of stroke/TIA (odds ratio, 4.59 [95% CI, 1.26–16.69];
Tables S2 and S3).
May 2023   1207
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Figure 1. Flow of participants for optical coherence tomography (OCT) examination of patent foramen ovale.
PFO indicates patent foramen ovale. aIncludes 5 patients with transient ischemic attack alone. bPresence of high-risk activities or anatomical
features related to PFO.
In the stroke group, the thrombus burden was smaller
in patients with anticoagulation (n=8) than in those with-
out (n=35, including antiplatelet and nonantithrombotic;
thrombus number per patient: median [IQR], 1 [0–3]
versus 9 [5–13]; P<0.001 and total thrombus volume:
median [IQR], 0.002 [0–0.007] versus 0.03 [0.01–0.06]
mm3; P=0.002). Between the stroke patients with anti-
coagulation (n=8) and those with antiplatelet (n=25),
a significant difference was noted in the median (IQR)
thrombus number per patient (1 [0–3] versus 9 [6–14];
P<0.001) and total thrombus volume (0.002 [0–0.007]
versus 0.03 [0.01–0.08] mm3; P<0.001). In the migraine
group, the frequency of in situ thrombus was 85.2%
(n=23) in patients with aura and 22.7% (n=5) in those
without aura (P<0.001). Furthermore, the patients
with migraine with aura had a larger thrombus burden
than those without aura (thrombus number per patient,
median [IQR], 9 [2–27] versus 0 [0–0]; P<0.001 and
total thrombus volume, median [IQR], 0.05 [0.01–0.19]
versus 0 [0–0] mm3; P<0.001). The intraobserver and
interobserver reproducibility was high in the measure-
ment of total thrombus volume, and the Pearson corre-
lation coefficients were 96.9% and 93.6%, respectively
(P<0.001 for both).
1208   May 2023
In Situ Thrombus Within PFO
Abnormal endocardium within the PFO was detected
in 46 patients with in situ thrombus (71.9%; Figure 3)
but not in those without in situ thrombus. The most
common abnormality was endocardial surface irregular-
ity (39.3%), followed by endocardial surface discontinu-
ity (11.1%) and endocardial signal-poor lesions (5.1%).
In the latter group, there were 2 patients with superfi-
cial lesions and 4 with deep lesions. Between patients
with and without in situ thrombus, the differences in
all 3 types of abnormal endocardium were significant
(P<0.001, P<0.001, and P=0.02, respectively). No
individuals in the asymptomatic group had endocardial
abnormalities (Figure S25). During OCT examination,
endocardial folding was identified in 3 patients, which
disappeared after adjusting the position of the guiding
catheter’s tip and the OCT-lens marker.
Procedural Complications
Procedure-related migraine recurrence was detected in
2 patients in the migraine group. For these 2 patients,
oxygen inhalation with mask was administered immedi-
ately, and the symptoms resolved spontaneously within
3 to 5 minutes. The presence of in situ thrombi was
Stroke. 2023;54:1205–1213. DOI: 10.1161/STROKEAHA.122.041524
 Yan et al In Situ Thrombus Within PFO

Table. PFO Characteristics in the Stroke, Migraine, and Asymptomatic Groups

CLINICAL AND POPULATION

Total population* Stroke group Migraine group Asymptomatic
Characteristics (N=117) (n=43) (n=49) group (n=25) P value

SCIENCES
Age, y; mean (SD) 34.3 (11.3) 38.2 (10.6) 29.7 (10.2) 36.9 (11.6) <0.001

Sex, n (%) 0.18

 Men 42 (35.9) 20 (46.5) 14 (28.6) 8 (32.0)
 Women 75 (64.1) 23 (53.5) 35 (71.4) 17 (68.0)
Body mass index, kg/m2; mean (SD)† 23.1 (2.8) 23.7 (2.9) 22.5 (3.0) 23.2 (2.2) 0.11
Atrial septal aneurysm, n (%)‡ 5 (4.3) 3 (7.0) 0 (0) 2 (8.0) 0.09
Antithrombotic therapy, n (%) 39 (33.3) 33 (76.7) 6 (12.2) 0 (0) <0.001

PFO area, mm2; mean (SD)

 Minimum PFO area 4.33 (1.76) 3.97 (1.58) 3.65 (1.21) 6.30 (1.61) <0.001

 Distal PFO area 5.07 (2.02) 4.97 (1.90) 4.33 (1.83) 6.70 (1.65) <0.001

 Proximal PFO area 6.59 (2.32) 6.07 (2.69) 6.08 (1.81) 8.46 (1.45) <0.001

In situ thrombus within PFO

 Patients with in situ thrombus, n (%) 64 (54.7) 36 (83.7) 28 (57.1) 0 (0) <0.001

 Patients with free-floating thrombus, n (%) 20 (17.1) 9 (20.9) 11 (22.5) 0 (0) 0.04
 Thrombus number per patient, median (IQR) 2 (0–9) 7 (3–12) 2 (0–10) 0 (0–0) <0.001

 Thrombus number classification, n (%) <0.001

  
Small 37 (31.6) 21 (48.8) 16 (32.7) 0 (0)
  
Medium 19 (16.2) 13 (30.2) 6 (12.2) 0 (0)
  
Large 8 (6.8) 2 (4.7) 6 (12.2) 0 (0)
 Maximum thrombus diameter, mm; median (IQR) 0.20 (0.00–0.44) 0.35 (0.20–0.46) 0.21 (0.00–0.68) 0.00 (0.00–0.00) <0.001

 Total thrombus volume, mm3; median (IQR) 0.01 (0.00–0.04) 0.02 (0.01–0.05) 0.01 (0.00–0.05) 0.00 (0.00–0.00) <0.001

Abnormal endocardium within PFO, n (%)

 Patients with abnormal endocardium 46 (39.3) 27 (62.8) 19 (38.8) 0 (0) <0.001
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 Patients with endocardial surface irregularity 46 (39.3) 27 (62.8) 19 (38.8) 0 (0) <0.001

 Patients with endocardial surface discontinuity 13 (11.1) 10 (23.3) 3 (6.1) 0 (0) 0.006
 Patients with endocardial signal-poor lesion 6 (5.1) 3 (7.0) 3 (6.1) 0 (0) 0.50
IQR indicates interquartile range; and PFO, patent foramen ovale.
*Values expressed as mean (SD), n (%), or median (IQR).
†Calculated as weight in kilograms divided by height in meters squared.
‡Atrial septal aneurysm was defined as a bulging of the atrial septum of at least 10 mm beyond the plane of the atrial septum into either the right or left atrium.

subsequently confirmed within the PFO of each patient
(Figure 4). No abnormal findings on brain computed
tomography were identified a day after the procedure.
After a 6F diagnostic catheter crossed the PFO, 1
patient in the stroke group presented with an ST-seg-
ment–elevation with sinus bradycardia, which resolved
after oxygen inhalation and atropine injection. In situ
thrombi were identified within the PFO. A vagal reaction
occurred in another patient during a percutaneous punc-
ture of the femoral vein. No procedural complications
were reported during OCT examination or PFO closure
in other patients.
DISCUSSION
In this study, the frequency of in situ thrombus
within the PFO was particularly high in the stroke
and migraine groups. In contrast, no cases of in situ
thrombi were detected in the asymptomatic group.
These findings suggest that in situ thrombi play an
important role in the mechanism of most PFO-associ-
ated strokes and migraines, making them a potential
therapeutic target. Additionally, abnormal endocar-
dium was common in patients with in situ thrombus
and might be implicated in the formation of in situ
thrombus within the PFO.
In the stroke and migraine groups, microthrombi
within the PFO were identified in most patients. None
of the patients had known vascular risk factors that
might increase the risk of both venous thrombosis and
atherosclerotic disease.29–31 Furthermore, no asymp-
tomatic individuals had in situ thrombi or abnormal
endocardium within the PFO, excluding the possibility
that these abnormalities were related to micro injuries
following PFO crossing with guidewires and catheters.
In selected patients with PFO, antithrombotic therapy
was administered for both recurrent stroke prevention
and migraine resolution,6–12 and migraine was con-
sidered a risk factor for future ischemic stroke.32–34
Accordingly, the formation of embolic thrombi has been

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 Yan et al
CLINICAL AND POPULATION
SCIENCES
proposed as a putative mechanism for PFO-associated
stroke and migraines.2 The evidence from this study
suggests that in situ thrombus might be a common
mechanism linking PFO and stroke/migraine. Within
the PFO, the numbers and sizes of in situ thrombi
vary greatly, and there is a potential risk for thrombi
to translocate into the left atrium, especially under the
hemodynamic conditions of a right-to-left shunt. It is
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possible that different numbers and sizes of dislodged
thrombi result in different neurological disorders, rang-
ing from migraine (possible cerebral microemboliza-
tion without neuroimaging abnormality)2,13,35 and TIA to
ischemic stroke. In patients with PFO, in situ thrombus
is significantly associated with risk of stroke and could
become a valuable predictor.
1210   May 2023
In Situ Thrombus Within PFO
Figure 2. Optical coherence
tomography of in situ thrombus
within patent foramen ovale.
A, A small number of in situ thrombi: a
total of 6 thrombi were detected on the
endocardial surface with a total volume
of 0.034 mm3. B, A medium number of in
situ thrombi: a total of 13 microthrombi
were detected on the endocardial surface
with a total volume of 0.056 mm3. C, A
large number of in situ thrombi: a total of
33 microthrombi were detected on the
endocardial surface with a total volume of
0.166 mm3. D, An extremely large number
of in situ thrombi: a total number of 103
thrombi were detected with a total volume
of 3.21 mm3. Arrows, in situ thrombi.
Images are from high-resolution optical
coherence tomography.
Procedure-related migraine recurrence and in situ
thrombi were subsequently identified in 2 patients in the
migraine group. The microthrombi within the PFO may have
dislodged into the left atrium by the guiding catheter’s tip
or a right-to-left shunt secondary to angiography, and trav-
eled to the cerebral arteries, thereby triggering migraine
attacks. Preclinical research has confirmed that an intraca-
rotid injection of micron-sized particles can induce cortical
spreading depression (a biological substrate for migraine
attacks) without causing requisite tissue injury, and the
relationship is size and dose dependent.35 Migraine attacks
have occasionally been reported in patients during contrast
echocardiogram and contrast-enhanced transcranial Dop-
pler with the Valsalva maneuver.36–39 Although the tip of a
delivery sheath/dilator has a smooth and fine transitional
Figure 3. Optical coherence
tomography of abnormal
endocardium within patent foramen
ovale.
A, Endocardial surface irregularity:
multiple microspiculations were attached
to the endocardial surface (arrows),
whereas the adjacent surface was
smooth (arrowheads). B, Endocardial
surface discontinuity: a localized defect
was detected on the endocardial surface
(arrow). C, Endocardial superficial signal-
poor lesion: a well-delineated lesion with
low reflectivity (arrows) was limited to the
intima. D, Endocardial deep signal-poor
lesion: a heterogeneous lesion with low
reflectivity (asterisk) affected the intima
and subintima. In addition, the endocardial
surface above the lesion was irregular
(arrows). Images are from high-resolution
optical coherence tomography.
Stroke. 2023;54:1205–1213. DOI: 10.1161/STROKEAHA.122.041524
 Yan et al
Figure 4. Optical coherence tomography in patients with procedural migraine recurrence.
A, Sudden-onset severe migraine without aura occurred shortly after the passage of a 6F guiding catheter across the patent foramen ovale, and
in situ thrombi (arrows) were detected subsequently on the endocardial surface. B, Moderate migraine with severe aura occurred shortly after the
first right atrial angiography with the Valsalva maneuver, and in situ thrombi (arrowheads) were identified on the endocardial surface. Images are
from high-resolution optical coherence tomography.
taper on the surface of the exchange guidewire, cerebral
events associated with the PFO closure procedure have
been documented.40 Future studies should determine the
relationship between these procedural complications and
in situ thrombus formation within the PFO.
Regardless of the presumed mechanisms, OCT
enabled the in vivo visualization of in situ thrombi within
the PFO, which are a potential thromboembolic source
and can increase the risk of embolic events. Therefore,
in situ thrombus may become a therapeutic target for
antithrombotic therapy or prophylactic PFO closure. For
patients with in situ thrombi, particularly those with a large
Downloaded from http://ahajournals.org by on December 7, 2023
number of thrombi, a potential risk of procedure-related
embolization during conventional PFO closure exists. In
situ thrombus formation within the PFO is likely multifac-
torial, and an abnormal endocardium might be a contrib-
uting factor, as indicated in our results. Further research
is required to investigate the biological and genetic fac-
tors involved in in situ thrombus formation, which might
provide additional insights into the related mechanisms.
Limitations
This study had several limitations. First, this was a single-
center study, and only Chinese patients were included,
which limits the study’s generalizability. Second, only
PFO cases with medium-to-large shunts were analyzed;
it remains unknown how the findings would differ in
PFO cases with smaller shunts, which may be associ-
ated with a greater risk of stroke recurrence.41 Third, an
atrial septal aneurysm might increase the risk of embolic
events in patients with PFO; however, this aspect was
not fully explored due to the small number of patients
with both PFO and atrial septal aneurysms.42 Fourth, the
use of OCT catheters in patients with PFO is off-license;
the poor field of view may have caused some PFO
parameters to be underestimated, such as the in situ
thrombus or abnormal endocardium frequencies and
thrombus number and volume. Fifth, the frequency and
size of in situ thrombus within the PFO might be further
Stroke. 2023;54:1205–1213. DOI: 10.1161/STROKEAHA.122.041524
In Situ Thrombus Within PFO
CLINICAL AND POPULATION
SCIENCES
underestimated in the stroke group due to the use of
antithrombotic therapy. Sixth, it was clinically difficult to
exclude the possibility of silent systemic microemboli-
zation, especially in the asymptomatic group. Seventh,
pediatric patients were excluded from this study, and
further research is required in this population. Eighth,
the use of the 6F/8F guiding catheter failed to create a
sufficient blood-free field in some individuals because of
the large size and complexity of the PFOs. Finally, given
that this study was based on a cross-sectional design
with a limited sample size and potential selection bias, it
was difficult to clarify the causal association between in
situ thrombus and stroke.
Conclusions
In the stroke and migraine groups, the frequency of in
situ thrombus within the PFO was particularly high. No
cases of in situ thrombi were reported in the asymptom-
atic group. There was no significant difference in the
in situ thrombus size between the stroke and migraine
groups. The formation of in situ thrombus might play
a role in PFO-associated strokes and migraines, and
the detection of in situ thrombus within the PFO might
prompt antithrombotic therapy or transcatheter clo-
sure to prevent potential embolic events. In situ thrombi
were detected more frequently in patients with migraine
with aura than in those with migraine but without aura,
thereby suggesting the need for additional studies. Fur-
ther research is required to investigate the mechanisms
of in situ thrombus formation and determine its role in
PFO risk stratification.
ARTICLE INFORMATION
Received October 5, 2022; final revision received December 31, 2022; accepted
February 20, 2023.
Affiliations
Department of Structural Heart Disease (C.Y., P.Y.), Department of Cardiol-
ogy (T.G.), Department of Echocardiogram (L. Wan), and Department of Nuclear
May 2023   1211
 Yan et al
Medicine (L. Wang, W.F.), Fuwai Hospital, Beijing, China. Department of Cardiol-
CLINICAL AND POPULATION
ogy, Beijing Tongren Hospital, China (H.L.). Department of Cardiology, Affiliated
Hospital of Xuzhou Medical University, China (C.W.). Abbott Vascular, China (H.Y.).
Acknowledgments
SCIENCES
We thank Jie Wang (Abbott Vascular, China) and Shiguo Li (Department of Struc-
tural Heart Disease, Fuwai Hospital) for help in OCT examinations and Minsheng
Liu (Department of Neurology, Peking Union Medical College Hospital) for help
in neurological evaluations. We also thank Zhenhui Zhu and Weichun Wu (Depart-
ment of Echocardiogram, Fuwai Hospital) for help in echocardiogram examina-
tions and Zhennan Lin and Xiangfeng Lu (Department of Epidemiology, Fuwai
Hospital) for help in statistical analysis. They were not compensated for their
contributions.
Sources of Funding
This work was supported by grant 61975240 from the National Natural Science
Foundation of China and grant 2020-I2M-C&T-B-065 from the Chinese Acad-
emy of Medical Sciences Innovation Fund for Medical Sciences.
Disclosures
None.
Supplemental Material
Supplemental Methods
Figures S1–S25
Tables S1–S3
Videos S1–S2
STROBE Statement
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