Recurrent Patent Foramen Ovale-Related Cerebral Infarcts Alternately Causing Bilateral Hand Paresis

Isolated hand paresis is a rare presentation of stroke, which mostly results from a lesion in the cortical hand motor area, a knob-like area within the precentral gyrus. I report the case of a patient who experienced recurrent ischemic stroke alternately involving bilateral hand knob areas, causing isolated hand paresis. There was no abnormal finding on brain and neck magnetic resonance angiography, transthoracic echocardiography, and 48-h Holter monitoring, and there were no abnormal immunologic and coagulation laboratory findings. The only embolic source was found to be a patent foramen ovale, which was proven on transesophageal echocardiography. The patient underwent percutaneous device closure of patent foramen ovale after alternately repeated paresis of both hands despite antiplatelet treatment. This case suggests that ischemic stroke affecting the cortical knob area, albeit extremely rare, may recur due to a patent foramen ovale, and it necessitates complete investigation, including transesophageal echocardiography, to identify possible embolic sources.

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Comparison of Frequencies of Patent Foramen Ovale and Thoracic Aortic Atherosclerosis in Patients With Cryptogenic Ischemic Stroke Undergoing Transesophageal Echocardiography

The American Journal of Cardiology ◽

10.1016/j.amjcard.2011.07.058 ◽

2011 ◽

Vol 108 (12) ◽

pp. 1815-1819 ◽

Cited By ~ 12

Author(s):

Xiaoyan Gu ◽

Yihua He ◽

Zhian Li ◽

Michael C. Kontos ◽

Walter H.J. Paulsen ◽

...

Keyword(s):

Ischemic Stroke ◽

Transesophageal Echocardiography ◽

Patent Foramen Ovale ◽

Aortic Atherosclerosis ◽

Foramen Ovale

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Abstract 3266: Detection Of Patent Foramen Ovale By Transesophageal Echocardiography and Contrast-Enhanced Cardiac Magnetic Resonance In Patients With Cryptogenic Stroke.

Circulation ◽

10.1161/circ.116.suppl_16.ii_735 ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Alfonso Sestito ◽

Pasquale Santangeli ◽

Priscilla Lamendola ◽

Fabio Pilato ◽

Christian Colizzi ◽

...

Keyword(s):

Ischemic Stroke ◽

Cardiac Magnetic Resonance ◽

Magnetic Resonance ◽

Transesophageal Echocardiography ◽

Patent Foramen Ovale ◽

Valsalva Maneuver ◽

Contrast Echocardiography ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Contrast Enhanced

Background. In ≈ 40% of patients with acute ischemic stroke, the cause remains undefined (cryptogenic stroke). Previous studies, using contrast echocardiography, showed a significant prevalence of a patent foramen ovale (PFO) in patients with cryptogenic stroke < 55 years of age, suggesting a causal role through paradoxical embolism. Contrast transesophageal echocardiography (TEE) is considered the gold standard for PFO detection. Recently, however, cardiac magnetic resonance (CMR) was also shown to reliably detect PFO. In this study we compared the accuracy of CMR and TEE in detecting PFO in a group of patients with cryptogenic stroke. Methods and Results . Sixteen patients (age 50 ± 13 years, 9 males) with cryptogenic ischemic stroke underwent contrast-enhanced TEE and contrast CMR for detection of possible PFO. Both imaging studies were performed during Valsalva maneuver. PFO grading results were assessed visually both for TEE and CMR, according to the entity of contrast passage in the left atrium (grade 0 = no PFO; grades 1, 2 and 3 = mild, medium and wide PFO, respectively). Nine patients (56%) were identified to have a PFO by contrast TEE. Contrast-enhanced CMR identified a PFO in only 5 (56%) of these patients. None of the 7 patients without PFO at TEE was shown to have a PFO at CMR. TEE showed a grade 1 PFO in 4 patients, a grade 2 PFO in 3 and a grade 3 PFO in 2 patients. Of these patients, CMR failed to identify PFO in all patients with a grade 1 PFO at TEE and underestimated the degree of the shunt in the other patients. Conclusions. Our data suggest that TEE should be considered the non-invasive diagnostic reference test to detect and characterize PFO in patients with ischemic cryptogenic stroke.

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