\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Cryptogenic Stroke in an Adult Sudanese Female with Interatrial Septal
Aneurysm: A Case Report}



\author[1]{Mahmoud  Salih Daoud}%
\author[2]{Ejlal Ahmed.E.  Abushama}%
\author[2]{Abdallah Hassan}%
\author[3]{Mohammed Eljack}%
\author[4]{Khabab  Mohamed Ahmed}%
\author[4]{Mazin S. Hassan Haroun}%
\author[4]{Elfatih Hasabo}%
\author[5]{Duaa Elshiekh}%
\author[1]{Sulieman  Abdelkareim G. Mohammed}%
\author[2]{Ahmed Eltayeb}%
\author[6]{Yousif Naemallah}%
\author[7]{Alameen Ahmed}%
\author[8]{Mohamed  Yusif}%
\author[6]{Asmaa Esam}%
\author[9]{Sara Nasreldeen}%
\author[6]{Rowida Babikir  Osman Eltayeb}%
\affil[1]{University of Gezira Faculty of Medicine}%
\affil[2]{Registrar of Internal medicine, Department of Neurology, Medani Teaching Hospital, Wad Medani, Sudan}%
\affil[3]{University of Bakhtalruda Faculty of Medicine and Health Sciences}%
\affil[4]{University of Khartoum Faculty of Medicine}%
\affil[5]{Registrar of Internal medicine, Department of Neurology, Medani Teaching Hospital, }%
\affil[6]{Registrar of Internal medicine, Department of Neurology, Medani Teaching Hospital}%
\affil[7]{Registrar of Internal medicine, Department of Neurology, Medani Teaching Hospital,}%
\affil[8]{Medani teaching hospital}%
\affil[9]{Registrar of Internal medicine, Department of Neurology, Medani Teaching Hospita}%


\vspace{-1em}



  
  \date{June 17, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\textbf{Cryptogenic Stroke in an Adult Sudanese Female with Interatrial
Septal Aneurysm: A Case Report}

Mahmoud Hussien Salih Daoud\textsuperscript{1}, Ejlal Ahmed.E.
Abushama\textsuperscript{2}, Abdallah H. Mahmmoud\textsuperscript{3},
Mohammed Mahmmoud Fadelallah Eljack\textsuperscript{4}, Khabab Abbasher
Hussien Mohamed Ahmed\textsuperscript{5}, Mazin S. Hassan
Haroun\textsuperscript{6}, Elfatih A. Hasabo\textsuperscript{7}, Duaa
Baderaldeen Ibraheem Elsheikh\textsuperscript{8}, Sulieman Abdelkareim
G. Mohammed\textsuperscript{9}, Ahmed Eltayeb O.
Eltayeb\textsuperscript{10}, Yusif Abduelmagid M.
Naimallah\textsuperscript{11}, Alameen Ahmed Alameen
Ahmed\textsuperscript{12}, Mohamed Yusif Mohamed
Yusif\textsuperscript{13,} Asmaa Esam Abbas Mokhtar\textsuperscript{14},
Sara Nasreldeen Ibrahim Awadalbari\textsuperscript{15}, Rowida Babikir
Osman Eltayeb\textsuperscript{16}

\textbf{Affiliations}

\begin{enumerate}
\tightlist
\item
  Consultant physician and neurology Specialist, Department of
  Neurology, Medani Teaching Hospital, Wad Medani, Sudan,
  dr.mhs.24@hotmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, abwshamhajlalahmd@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, abdallahhassan8898@gmail.com
\item
  MBBS, Faculty of Medicine and Health Sciences, University of
  Bakhtalruda, Ed Dueim, Sudan. m.mahmmoud96@gmail.com
\item
  MBBS, Faculty of Medicine, University of Khartoum, Khartoum, Sudan.
  Khabab9722@gmail.com, ORCID: 0000-0003-4608-5321
\item
  MBBS, Faculty of Medicine, University of Khartoum, Khartoum, Sudan,
  Mazinsalaheldien@gmail.com
\item
  MBBS, Faculty of Medicine, University of Khartoum, Khartoum, Sudan,
  elfatih.ahmed.hasabo@gmail.com, ORCID: 0000-0001-9727-8620
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan. Duaaelshiekh@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan,
  Suliemanabdelkareim33128@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, Dr.a.eltayeb88@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, Yousifnaemallah17@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, wadahmed571@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, www.mohamedyoudif1993@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, www.asmaaesam1991@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, saranasreldeen2016@gmail.com
\item
  Registrar of Internal Medicine, Department of Neurology, Medani
  Teaching Hospital, Wad Medani, Sudan, omgomanaomgomana7@gmail.com
\end{enumerate}

\textbf{*Corresponding Author:}

Dr. Khabab Abbasher Hussien Mohamed Ahmed, Faculty of Medicine,
University of Khartoum, Khartoum, Sudan, ZIP: 11111, Email:
Khabab9722@gmail.com, ORCID:\emph{https://orcid.org/0000-0003-4608-5321}

\textbf{Abstract}

An atrial septal aneurysm (ASA) is a saccular defect of the atrial
septum, and it may be associated with congenital heart disease.
Cryptogenic strokes are strokes of unknown origins, and ASA may be one
of these causes. In this case report, we described a cryptogenic stroke
in an adult Sudanese female with an interatrial septal aneurysm.

\textbf{Keywords} : Atrial; Septal; Aneurysm; Stroke; Cardiology; Sudan

\textbf{Key clinical Message:}

Although it's a very rare incidence, the presentation of acute stroke in
young patients should raise demands for detailed evaluation reaching up
to invasive investigations with echocardiography presenting the
cornerstone in such cases.

\textbf{Introduction:}

An atrial septal aneurysm (ASA) is an uncommon but well-known structural
saccular malformation of the atrial septum that bulges into the right or
left atrium without clinical significance {[}1{]}. This lesion is
commonly associated with congenital heart diseases such as patent
foramen ovale, atrial septal defect, mitral valve prolapse, tricuspid
valve prolapse, Marfan syndrome, sinus of Valsalva aneurysm, and aortic
dissection. However, it may be caused by acquired heart disease
{[}2,3{]}. It is usually asymptomatic with clinical, cardiologic, and
electrocardiographic examinations failing to reveal its presence
{[}3{]}. Only a few examples of atrial septal aneurysms have been
described in connection with cerebral embolism; either from a
paradoxical embolism of venous thrombi through a right to left shunt or
passage of a thrombus formed on the left atrial side of the aneurysm
with atrial fibrillation {[}1,2{]}. The following report summarizes
cryptogenic stroke in an adult Sudanese female with an interatrial
septal aneurysm.

\textbf{Case presentation:}

A 43-year-old female with no history of diabetes or hypertension
presented with sudden onset left-sided mouth deviation and right-side
weakness. There are no seizures or loss of consciousness, and there are
no sphincteric disturbances.

On examination, the patient was aphasic, with a GCS of 8/15, a pulse of
100 beats per minute regular, and a blood pressure of 130/80 mmHg. A
central nervous system examination revealed right-side crossed
hemiplegia with horizontal nystagmus and pyramidal power loss. The
cardiovascular system, chest, and abdomen were all examined and found to
be normal. The following tests were performed: CBC, RFT, electrolytes,
RBG, lipid profile, ESR, and ECG, all of which were normal.
Thrombophilia screening is not available.

Transthoracic echocardiography revealed an aneurysmal interatrial septum
(according to Hanley's diagnostic criteria), no Patent Foramen ovale or
another shunt, no intracardiac thrombus, and no vegetation. However, the
presence of bulbar cranial nerve palsy made obtaining a transoesophageal
echo difficult. Holter monitoring for 24 hours revealed episodes of
sinus tachycardia.

Carotid Doppler was normal, MRI of the brain revealed an infarction on
the territory of the left posterior cerebral artery and the middle
cerebral artery (Figure 1), and MRA revealed occlusion of the left
posterior cerebral artery (Figure 2).

The patient received IV fluids, statins, aspirin, and prophylactic
heparin and started oral anticoagulants 10 days after the stroke. She
was clinically followed for two weeks and showed remarkable improvement
with GCS 10/15 before being discharged in good condition on rivaroxaban
20 mg orally once per day for life.

She was evaluated at the referral clinic two weeks later and showed
complete resolution of bulbar symptoms and aphasia with GCS 15/15 while
still in grade 1 power.

\textbf{Discussion}

We present a case of a 43-year-old female who had left posterior
cerebral artery ischemia and an atrial septum aneurysm on
echocardiography. An atrial septum becomes aneurysmal when an atrial
dilated segment bulges at least 15 mm beyond the atrial septum's surface
level {[}4{]}. Atrial septal aneurysm and/or patent foramen ovale are
thromboembolic heart defects. Both occur in 20\% of the population and
contribute to cryptogenic ischemic strokes in the younger population.
Cryptogenic strokes are those with unknown or unexplained aetiologies
{[}5{]}. Cerebrovascular events can occur in up to 52\% of patients with
atrial septum aneurysms. However, this significant incidence is found in
patients with a clear cardiac thromboembolic cause of the
cerebrovascular episode. The pathogenesis of stroke in people with
atrial septum aneurysms is not completely known. It could be related to
the production of direct thrombi at the atrial septum aneurysm {[}6{]}.
Right-to-left paradoxical embolism of venous thrombi through a patent
foramen ovale is another cause of cerebral embolism, as is the
transition of a thrombus developed on the left atrial side of an
aneurysm {[}5,7{]}. Transoesophageal echocardiography is commonly used
to detect atrial septal aneurysms in individuals with unexplained
strokes {[}8{]}. Our patient experienced cerebrovascular symptoms, but
transthoracic echocardiography revealed only aneurysmal interatrial
septum, no Patent Foramen ovale or another shunt, no intracardiac
thrombus, or vegetation, ruling out several of the known potential
explanations. However, because of the presence of bulbar cranial nerve
palsy, we were unable to get a transoesophageal echo, which could have
clarified the cause of the stroke. Possible underlying mechanisms
include the formation of a thrombus on the aneurysm's left atrial side
or the development of interatrial fenestrations that resulted in a
right-to-left shunt. Because hypertension has been linked to cryptogenic
stroke, we believe it played a role in the aetiology of cryptogenic
stroke in our patients {[}9{]}. Our case emphasizes the significance of
atrial septum aneurysm as a potential risk factor for cryptogenic
ischemic strokes. To the best of our knowledge, this is the first case
of a symptomatic stroke patient with an atrial septal aneurysm on
transthoracic echocardiography that does not have a patent foramen ovale
or any other aetiology. More research is needed to determine the
mechanism underlying such cerebrovascular events.

\textbf{Conclusion:}

In conclusion, cryptogenic strokes are strokes of undetermined origin.
Atrial septum aneurysm may be an important risk factor for cryptogenic
strokes even if evidence of a thromboembolic source is not observed,
such as patent foramen ovale, shunts, or vegetations.

\textbf{List of abbreviations:}

GCS stands for Glasgow coma scale.

CBC stands for a complete blood count.

RFT stands for Renal Function Test.

ECG stands for electrocardiogram.

RBG stands for random blood glucose.

ESR stands for estimated sedimentation rate.

BP stands for blood pressure.

MRI stands for magnetic resonance imaging.

MRA stands for Magnetic resonance angiogram.

IV stands for Intravenous

\textbf{Declarations:}

Ethics approval: This is a case report that does not require approval
from the institute's human research committee.

Consent for publication: The patient provided written permission for
this information to be published. The patient provided written consent
for his personal clinical information to be published in this study.

Data availability: Data and materials are available upon reasonable
request from the corresponding author.

Competing interests: The authors have no conflicts of interest to
declare.

Funding: The authors funded the study themselves.

Contributions of the authors: MHSD: The first author collected the data,
analysed the findings, and wrote the manuscript. EAEA, AHA, MMFE, KAHMA,
MSHH, EAH, DBIE, SAGM, AEOE, YAMNA, AAAA, MYMY, AEAM, SNIA, and RBOE:
authors wrote, revised, and edited the manuscript. The final manuscript
was read and approved by all authors.

Acknowledgements: The preprint of the paper was published in Authorea,

DOI: 10.22541/au.165460163.37912968/v1

\textbf{References} :

1. Cevik A, Oguz D, Pektas A, Ozdemir M, Olgunturk R. Resynchronization
therapy in an adolescent with pacemaker-related ventricular dysfunction.
Ann Pediatr Cardiol. 2012;5(1):97--8.

2. Sahid Imam Mallick S. Ischemic Stroke in an Atrial Septal Aneurysm
Individual- a Case Report -. Int J Curr Res Rev. 2015;7(7):32--4.

3. Pasquale G Di, Andreoli A, Grazi P, Dominici P, Pinelli G.
Cardioembolic stroke from atrial septal aneurysm. Stroke.
1988;19(5):640--3.

4. Silver MD, Dorsey JS. Aneurysms of the septum primum in adults. Arch
Pathol Lab Med. 1978 Feb;102(2):62-5. PMID: 579965.

5. El-Chami MF, Hanna IR, Helmy T, Block PC. Atrial septal abnormalities
and cryptogenic stroke: a paradoxical science. Am Heart Hosp J. 2005
Spring;3(2):99-104. doi: 10.1111/j.1541-9215.2005.04428.x. PMID:
15860996.

6. Schneider B, Hanrath P, Vogel P, Meinertz T. Improved morphologic
characterization of atrial septal aneurysm by transesophageal
echocardiography: relation to cerebrovascular events. J Am Coll Cardiol.
1990 Oct;16(4):1000-9. doi: 10.1016/s0735-1097(10)80354-7. PMID:
2212349.

7. Razaq M, Parihar RK, Saini G. Atrial septal aneurysm and
stroke.\emph{Ann Pediatr Cardiol} . 2012;5(1):98-99.
doi:10.4103/0974-2069.93726

8. Pearson AC, Nagelhout D, Castello R, Gomez CR, Labovitz AJ. Atrial
septal aneurysm and stroke: A transesophageal echocardiographic study. J
Am Coll Cardiol {[}Internet{]}. 1991;18(5):1223--9.

9. Dardick JM, Flomenbaum D, Labovitz DL, Cheng N, Liberman AL, Esenwa
C. Associating cryptogenic ischemic stroke in the young with
cardiovascular risk factor phenotypes. Sci Rep. 2021;11(1):275.
Published 2021 Jan 11. doi:10.1038/s41598-020-79499-1

\textbf{Figures}

\textbf{Figure 1:} MRI of the brain showing infarction on the territory
of the left posterior cerebral artery and middle cerebral artery.

\textbf{Figure 2:} MRA of the brain showing left posterior cerebral
artery occlusion.

\textbf{Hosted file}

\verb`Figures.docx`  available at \url{https://authorea.com/users/463509/articles/687806-cryptogenic-stroke-in-an-adult-sudanese-female-with-interatrial-septal-aneurysm-a-case-report}

\selectlanguage{english}
\FloatBarrier
\end{document}

