Wilfling Sibylle, Kilic Mustafa, Tsoneva Blagovesta, Freyer Martin, Olmes David, Wendl Christina, Linker Ralf A, Schlachetzki Felix
Department of Neurology, University of Regensburg, Medbo Bezirksklinikum Regensburg, Landshut 84034, Germany.
Department of Neurology, Municipal Hospital, Robert Koch Str. 1, Landshut 84034, Germany.
Brain Circ. 2022 Mar 21;8(1):50-56. doi: 10.4103/bc.bc_61_21. eCollection 2022 Jan-Mar.
Detecting the stroke etiology in young patients can be challenging. Among others, determining causality between ischemic stroke and patent foramen ovale (PFO) remains a complicated task for stroke neurologists, given the relatively high prevalence of PFOs. Thorough diagnostic workup to identify incidental vascular risk factors and rare embolic sources is crucial to avoid premature PFO closure suggesting successful secondary stroke prevention. In this paper, we report on a 38-year-old patient with recurrent vertebrobasilar territory, especially right posterior inferior cerebellar artery (PICA) territory strokes. After the initial suspicion of a left vertebral artery (VA) dissection was not confirmed by ultrasound and magnetic resonance imaging (MRI) and other major risk factors were excluded, a PFO was detected and closed. Successful PFO closure was confirmed by transesophageal echocardiography, yet recurrent transient-ischemic attacks and vertebrobasilar strokes, especially during nighttime and in the early morning, occurred despite various antiplatelet and antithrombotic regimes and a persistent right-to-left shunt was detected by bubble transcranial Doppler. Finally, MRI after another vertebrobasilar infarction detected a transient left VA occlusion that finally led to the diagnosis of a left VA pseudoaneurysm from an incident emboligenic dissection in the atlas segment. This pseudoaneurysm together with an anatomical variant of the right PICA originating with the right anterior inferior cerebellar artery from the basilar artery finally explained the recurrent ischemic events of the patient. After successful treatment with coil occlusion, the patient suffered no further stroke and recovered completely. In summary, stroke in the young remains a diagnostic challenge. The incidental finding of a PFO should not deter from thorough stroke workup and the follow-up of these patients including PFO closure verification should be performed under the guidance of vascular neurologists.
在年轻患者中检测中风病因可能具有挑战性。其中，鉴于卵圆孔未闭（PFO）的相对高患病率，确定缺血性中风与PFO之间的因果关系对中风神经科医生来说仍然是一项复杂的任务。进行全面的诊断检查以识别偶然的血管危险因素和罕见的栓子来源对于避免过早进行PFO封堵至关重要，这表明成功进行了二级中风预防。在本文中，我们报告了一名38岁的患者，其反复出现椎基底动脉区域，尤其是右后下小脑动脉（PICA）区域中风。在最初怀疑左椎动脉（VA）夹层未通过超声和磁共振成像（MRI）得到证实且其他主要危险因素被排除后，检测到并封堵了PFO。经食管超声心动图证实PFO封堵成功，但尽管采用了各种抗血小板和抗血栓治疗方案，仍发生了反复的短暂性脑缺血发作和椎基底动脉中风，尤其是在夜间和清晨，并且通过气泡经颅多普勒检测到持续的右向左分流。最后，在另一次椎基底动脉梗塞后进行的MRI检测到短暂的左VA闭塞，最终导致诊断为寰椎段偶发性致栓性夹层引起的左VA假性动脉瘤。这个假性动脉瘤连同起源于基底动脉右前下小脑动脉的右PICA解剖变异最终解释了该患者反复出现的缺血性事件。在成功进行线圈封堵治疗后，患者未再发生中风并完全康复。总之，年轻人中风仍然是一个诊断挑战。偶然发现PFO不应妨碍进行全面的中风检查，并且这些患者的随访，包括PFO封堵验证，应在血管神经科医生的指导下进行。
