Cardioembolic Stroke While Running In A Healthy 42-year Old Male

Abstract

HISTORY: A 42-year-old male runner with no prior medical history presented to the emergency department with acute right-sided hemiplegia and slurred speech. Symptoms presented during exertion while cresting a hill two kilometres into a seven kilometre routine morning run. Symptoms started with an inability of the right foot to clear the sidewalk and progressed with right arm weakness, tingling in the right side of the mouth/lips, right leg weakness/clumsiness, and slurred speech. Within 5 minutes he was unable to ambulate, and he experienced a visual aura during transport to the emergency department which developed into a migraine headache while admitted. He had a 30-year history of frequent migraine with aura most often presenting post-exercise. PHYSICAL EXAMINATION: On examination, his vital signs were normal, and a CT scan of his brain and CT angiogram of his head and neck were unremarkable. He had no evidence of dysarthria or aphasia, had a normal range of extraocular movements. There was no evidence of facial asymmetry, and motor and coordination capabilities as well as gait were normal. Right-sided weakness and fine-motor issues (writing fluency) impairment persisted after discharge. DIFFERENTIAL DIAGNOSIS: 1. Atypical migraine.2. Malignancy.3. Transient ischemic attack.4. Ischemic stroke. TEST AND RESULTS: 1. Echocardiogram and 24-hour Holter monitor: -Unremarkable.2. Thrombophilia screens and doppler ultrasound of the legs: -Negative.3. Echocardiogram with agitated saline: -Positive with moderate amount of bubbles present.4. Transthoracic echocardiogram with agitated saline -Revealed a patent foramen ovale (PFO) and atrial septal aneurysm. -Right-to-left shunting both at rest and with Valsalva. FINAL WORKING DIAGNOSIS: Presumed embolic left posterior lobe frontal infarct in the setting of an 8 mm PFO with a 20 mm tunnel and concomitant atrial septal aneurysm with an adjacent small 2 mm secundum atrial septal defect. TREATMENT AND OUTCOMES: 1. Avoid strenuous exercise or any activities requiring Valsalva movement. This is important in light of recommendations consistently suggesting exercising after stroke.2. Apixaban 5 mg twice daily.3. PFO-closure procedure using the GORE® CARDIOFORM Septal Occluder (Gore Medical, Phoenix, AZ) device.4. Aspirin monotherapy thereafter.