Cryptogenic stroke associated with patent foramen ovale in a collegiate volleyball athlete: a case report

Abstract

Cryptogenic stroke is a form of cerebral vascular accident that has an unknown origin and is rarely associated with patent foramen ovale (PFO) and migraine headaches. This is an uncommon occurrence in young, healthy, active adults, and it is increasingly rare for the episode to occur during an athletic competition. Stroke is easily recognizable with its distinct signs and symptoms, but it is also easily confused with many of its differential diagnoses, such as seizures or head trauma, if the episode occurs during an athletic competition. This case report describes the stroke episode, incidence of migraine headaches, diagnostic testing, and surgical management of a college female volleyball athlete who suffered a cryptogenic stroke associated with PFO during an athletic competition. Diagnostic testing included magnetic resonance imaging with contrast, electroencephalograph, lower extremity Doppler testing, and a transesophageal echocardiograph with agitated saline study. Surgical correction of the PFO included a cardiac catheterization percutaneous procedure based on fluoroscopic and echocardiograph imaging. After release from physicians, the athlete returned to full participation in the sport of volleyball, where she competed for the next 2 years without complications. The patient has reported no symptoms from stroke or PFO closure procedure in 3 years, and migraine headaches have decreased in severity, frequency, and duration.

Keywords: athlete; cryptogenic stroke; migraine headaches with aura; oral contraceptives; patent foramen ovale.

Figure 1.

Magnetic resonance imaging: A, transverse view slice of the brain showing area of diffusion restriction (approximately 2.6 cm in diameter) of the anterior left insular and temporofrontal area, consistent with an infarction. B, transverse view slice of the brain (immediately above Figure 1A) showing focus of diffusion restriction (approximately 6 mm) in the lateral left frontal convexity anterior to the motor strip. Inferiorly, below the level of the center of the larger infarction, there is a left posterior temporoparietal cortical focus of diffusion restriction measuring approximately 5 mm in diameter. There is a development of venous anomaly in the pons, present to the left of the midline, that is of questionable significance.

Figure 2.

Echocardiograph of the transesophageal echocardiograph procedure before agitated bubbles pass through the patent foramen ovale.

Figure 3.

Echocardiograph showing deployment of the Amplatzer mesh closure device (arrow) to seal the 14-mm patent foramen ovale anomaly in the atrial septum.