Different Strokes for Different Folks - Football

Abstract

HISTORY: 22-year-old D1 University Football Long Snapper presents to the training room for migraines. He’s had migraines for 6-7 years and 4 concussions since HS. The night prior he had a migraine in the temporal region associated with transient left-sided vision loss & left arm numbness for 30-40 minutes. A diffuse headache lasting for 4-5 hours followed. Sumatriptan relieved the pain. He’s had increased migraine frequency for the past 6 months. Episodes were described to his neurologist. MRI of the Brain & Cervical Spine were ordered. PHYSICAL EXAMINATION: AF VSS. NAD, well appearing. PERRLA, EOMI, NCAT Cranial nerves intact, no nystagmus, normal face symmetry, tongue & palate midline Sensation intact Strength/tone normal bilaterally Reflexes 2+ Coordination and gait intact DIFFERENTIAL DIAGNOSIS: Migraine (hemiplegic/retinal) with brainstem aura Transient Ischemic Attack or Cerebrovascular Accident Cerebral Aneurysm Intracranial space-occupying lesion Dissection Syndrome TESTS & RESULTS: MRI Brain w/o contrast: small subacute infarct in the right cerebellum. No mass effect or ICH. MRI C-Spine: mild degenerative changes. No canal stenosis Admitted to the hospital further work up. Labwork negative. US LE w/ doppler - No DVT CTA head/neck: Normal vessels. No dissection MRA Neck: Common and internal carotid arteries w/ normal caliber and contour. Normal vertebral arteries. Left vertebral a. is dominant. No flow-limiting stenosis. TTE: Small right to left shunt on agitated saline contrast study suggestive of a patent foramen ovale. Transcranial Doppler US Bubble Study: Right to left shunting, showering bubbles FINAL / WORKING DIAGNOSIS: Cryptogenic subacute right cerebellar infarct secondary to a PFO TREATMENT AND OUTCOMES: Aspirin & Clopidogrel started inpatient. Discharged after workup. PFO closure and transseptal left heart catheterization completed with Cardiovascular Surgery. Continue ASA and Clopidogrel for 6 months post-op; ASA lifelong. Retired from the football team. Repeat TTE: well seated closure device. Cardiac rehabilitation for first 2 months post-op. 4 months post-op: running about 1 mile daily, 6 days/week. Endurance and circuit training with low weights. He’s been migraine free since 2 months post-op. He takes Indomethacin as needed. Follow up scheduled for 6 months post-operation.