TOP 2025: An update to the Transparency and Openness Promotion Guidelines.

Approximately 30% of ischemic strokes are classified as cryptogenic, indicating no identifiable cause despite comprehensive diagnostic evaluation []. Among patients with cryptogenic stroke, a patent foramen ovale (PFO) is detected in roughly 40%–50%, a prevalence rate that is substantially higher than observed in the general population (~25%) [,]. A PFO is a flap-like communication between the right and left atria that can permit right-to-left shunting, allowing venous thrombi to bypass the pulmonary circulation and enter the cerebral arterial system and cause a stroke. This mechanism, termed paradoxical embolism, is most commonly associated with PFO or other intracardiac shunts such as atrial septal defect and is estimated to account for approximately 5% of all ischemic strokes and up to 10% of strokes in younger adults []. Recent evidence suggests PFO may be a more common stroke mechanism than previously recognized []. A recent Special Communication in  proposed the term as a “…distinct entity of ischemic stroke for all patients presenting with superficial, large deep, or retinal infarcts in the presence of a medium-risk to high-risk PFO and no other identified likely cause” (p. 884) []. PFO-associated strokes are challenging because clinicians must determine whether the PFO is truly causal and then balance uncertain risks and benefits of closure versus medical therapy. Current guidelines now recommend transcatheter PFO closure with long-term antiplatelet therapy in younger patients (<60 years of age) when the PFO is considered the most likely stroke mechanism []. There are extensive clinical guidelines addressing return to physical activity after ischemic stroke [–]. One recent systematic scoping review of post stroke physical activity engagement suggested the majority of studies still report low physical activity despite established clinical guidelines and recommendations []. However, there is no evidence-based guidance for returning to physical activity after a PFO-associated stroke and after transcatheter closure. PFO-associated stroke survivors occupy a unique intersection between neurology, cardiology, and stroke rehabilitation, where traditional stroke recovery frameworks may not fully translate to patients who have experienced a PFO-associated stroke. The cardiac etiology and use of transcatheter closure in PFO-associated stroke may introduce clinical and experiential factors not typically observed in the broader stroke population, which may have potential implications for returning to physical activity. We recently proposed four key actions and research questions to advance knowledge on physical activity after PFO-associated stroke and transcatheter closure to guide and promote research on physical activity and PFO-associated stroke [].