Therefore, it is extremely important to continue echocardiographic imaging not only during the strain phase but also the release phase of the Valsalva maneuver so as not to miss the diagnosis of paradoxical embolism (2). Furthermore, clinicians should not just write on the request form “to rule out cardiogenic emboli” when sending a patient with cryptogenic stroke to the echocardiographic laboratory. What the echocardiographic technician or even the echocardiographer usually does is concentrate on ruling out a left atrial thrombus, a left atrial myxoma, mitral valve prolapse, vegetations on the mitral or aortic valve, a left ventricular thrombus or ventricular aneurysm, dilated cardiomyopathy, or atherosclerotic plaques in the ascending aorta. Of couse, it is also possible to detect an interatrial septal defect or an atrial septal aneurysm or a PFO, the last usually only on transesophageal echocardiography. To rule out paradoxical embolism, one needs to reverse the interatrial pressure gradient, because normally left atrial pressure is higher than right atrial and therefore no right-to-left shunt will occur, unless we artificially reverse this gradient by raising the right atrial pressure above the left atrial, such as by performance of a Valsalva maneuver. Therefore, it is very important to put on the requisition form to the echocardiographic laboratory not just “to rule out cardiogenic emboli” but also to “rule out paradoxical embolism.” For the latter it is not only necessary during echocardiography to perform a Valsalva maneuver following the intravenous injection of agitated saline or contrast medium but also to obtain images during both the strain phase and the release phase of the Valsalva maneuver (2- 14).