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.