Ischemic stroke in a young patient: role of a bubble test

Abstract

A 29-year-old female patient, with a known history of erythematosus disseminated lupus, consulted for a left hemiplegia with aphasia and central facial paralysis, the cerebral CT scan showed an ischemic stroke in the territory of the superficial right sylvian artery. The neurologist asked as part of the etiological assessment for an echography of the supra-aortic trunks which appeared normal as well as a trans-thoracic echography which appeared initially without anomalies. By taking into consideration the young age of the patient and his history of systemic disease, we mentioned a permeable oval foramen (FOP), then we completed the assessment with a bubble test with concomitant transthoracic echocardiography which revealed a passage of more than 30 bubbles through the FOP (A) after valsalva maneuver. FOP is present in 25% of individuals. Most of the time, patients with this anomaly are asymptomatic. Nevertheless, it is important to mention its presence in front of any signs of arterial ischemia such as a stroke attesting to a paradoxical embolism. Its pathophysiology is based on a persistent, intracardiac right-left shunt with the migration of a thrombus from the right cavities to the left heart through the FOP. The Management is based either on a drug treatment, or on the closure of the intracardiac shunt within a synthetic prosthesis, by surgery or percutaneously.