(Kiosk 3) Right MCA Infarction Caused by a Paradoxical Embolus Due to Patent Foramen Ovale: A Case Report

Case Diagnosis: 57 year-old female with left sided weakness found to have a right MCA syndrome.

Case Description or Program Description: A 57 year-old female presented after being found down by her husband, with complaints of left sided weakness. Initial CT Head showed right insular ribbon and hyperdense MCA sign, followed by CTA Head with evidence of right M1 occlusion. Patient then underwent TICI3 revascularization. Hospital course was complicated by malignant edema and a decompressive hemicraniectomy was performed. Further work-up done demonstrated venous doppler of lower extremities with left soleal DVT, and echocardiogram showing microbubbles in left heart after agitated saline injection. She was started on apixaban with transition to aspirin monotherapy after 3 months, and a heart monitor was placed.

Setting: Acute inpatient rehabilitation floor.

Assessment/Results: Initial CT Head of the patient’s brain revealed ischemic infarct in R MCA territory. As part of her work up, echocardiogram revealed right to left shunting during bubble study, indicating a patent foramen ovale. Etiology of stroke likely embolic versus arrhythmia.

Discussion (relevance): This case demonstrates the sequela of underlying anatomical pathology on various organ systems. In particular, this patient’s patent foramen ovale led to an embolus being dislodged into the systemic circulation, resulting in an ischemic infarct in the brain. This, in turn, had several lasting adverse effects on the patient’s functional status and quality of life. Paradoxical emboli are rare cases that can be devastating. It is imperative that physiatrists take into account the various pathologic processes that can contribute to cerebrovascular insults so as to optimize care in a patient-centered manner.

Conclusions: Underlying structural cardiac pathology can lead to paradoxical emboli resulting in a cerebrovascular insult. Various cardiovascular risk factors can impair the potential for progress in rehabilitation post-stroke.