2 day history of occipital headache and visual field defect
Quadrantanopsia (right upper outer visual field defect).
Serum anticardiolipin positive for "lupus-like" anticardiolipin antibodies.
Echocardiogram - a patent foramen ovale (PFO) diagnosed echocardiographically with a bubble study.
Plain CT: area of decreased attenuation left medial occipital lobe involving cortex and subcortical white matter
MRI w/ DWI: area of "light bulb bright signal" left medial occipital lobe - intracellular cytotoxic edema
MRA: normal (not shown)
calcarine cortex infarction due to:
Dx: Cerebral infarction, occipital lobe, presumed due to paradoxical embolus through a patent foramen ovale (PFO) diagnosed echocardiographically with a bubble study.
Dx Confirmed by:
PFO closed via percutaneous transcatheter PFO closure.
This patient may also be hypercoagulable from the anticardiolipin Ab and may need life long anticoagulation. Please refer to factoid for further discussion.
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Approximately 1 million people suffer a symptomatic stroke each year in the United States with 160,000 of these considered cryptogenic strokes. A stroke is classified as cryptogenic when no cause is identified after extensive evaluation. This occurs in 25-40% of strokes in young adults.
Relatively recently, paradoxical embolism through an atrial communication such as a patent foramen ovale (PFO) or atrial septal defect (ASD) has been recognized as a cause cerebral ischemic events previously considered cryptogenic. Approximately 40-70% of patients suffering cryptogenic strokes have PFOs whereas the incidence of PFOs in the general population is 10-23%. Stroke patients with PFOs are also at risk for recurrent cerebral thromboembolic events at a rate of 3.4-3.8% per year.
Mechanistic theories of paradoxical embolism include right to left shunting of venous thromboemboli and the PFO acting as a tunnel within which thrombus can develop secondary to stasis with embolization occurring during periods of valsalva.
Diagnosis of a PFO or ASD can be made with transthoracic or transesophageal echocardiography using agitated saline with bubbles for a contrast agent.
Current management includes medical therapy with antiplatelet or anticoagulant medication, surgical closure and the more recent development of transcatheter closure with a variety of closure devices. Studies investigating transcatheter device closure of PFOs have been encouraging.
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