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.