Working Diagnosis:
Cerebrovascular accident (CVA) in the setting of PFO

Treatment:
At his follow-up sports medicine appointment, the patient continued to report mild symptoms and was prescribed an oral prednisone burst, 40 mg a day for a total of five days. He was placed on aspirin 81 mg daily for long term treatment.

Outcome:
One month after hospitalization the patient reported complete resolution of right upper extremity symptoms, with 95-98% resolution of weakness in his right lower extremity.

Six weeks after hospitalization the patient was cleared to play professional basketball by cardiology and neurology. Surgical intervention to close the PFO was recommended during the offseason.

Author's Comments:
Patent foramen ovale (PFO) should be considered as a possible etiology of acute neurologic symptoms, particularly in otherwise healthy young athletes. When searching for PFO, it is important to recognize the low sensitivity of trans-thoracic echocardiography. In patients for whom a high index of suspicion for PFO exists, further imagining, including TEE or trans-cranial doppler (TCD), may be warranted. Note that TCD is more sensitive but less specific than TEE in detecting PFO. Patients with TIA or CVA due to PFO should undergo cardiovascular risk reduction strategies including hyperlipidemia control with statins, blood pressure optimization, and lifestyle modification.

Editor's Comments:
When evaluating patients with acute onset of unilateral neurologic symptoms, one must maintain a high index of suspicion for cerebrovascular pathology, even in the absence of classic cardiovascular risk factors. Patent foramen ovale (PFO) is a relatively common anatomical variation, occurring in about 25% of the population, and should be considered as a possible underlying condition in otherwise healthy patients presenting with stroke-like symptoms. While PFOs are often asymptomatic, they do place patients at risk for cryptogenic stroke, caused by a blood clot passing from the right to the left atrium. Treatment options include medical management with anticoagulants or antiplatelet agents, in addition to consideration of surgical intervention for PFO closure to reduce the risk of future events.

References:
Miranda B, Fonseca AC, Ferro JM. Patent foramen ovale and stroke. J Neurol. 2018 Aug;265(8):1943-1949. doi: 10.1007/s00415-018-8865-0. Epub 2018 Apr 21. PMID: 29680895.

Katsanos AH, Psaltopoulou T, Sergentanis TN, Frogoudaki A, Vrettou AR,
Ikonomidis I, Paraskevaidis I, Parissis J, Bogiatzi C, Zompola C, Ellul J, Triantafyllou N, Voumvourakis K, Kyritsis AP, Giannopoulos S, Alexandrov AW, Alexandrov AV, Tsivgoulis G. Transcranial Doppler versus transthoracic echocardiography for the detection of patent foramen ovale in patients with cryptogenic cerebral ischemia: A systematic review and diagnostic test accuracy meta-analysis. Ann Neurol. 2016 Apr;79(4):625-35. doi: 10.1002/ana.24609. Epub 2016 Mar 11. PMID: 26833864.

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