Recurrent vertebrobasilar strokes and transient-ischemic attacks with challenging workup: Case report

Area of Science:

• Neurology
• Vascular Neurology
• Cardiology

Background:

• Detecting stroke etiology in young patients is challenging.
• Patent foramen ovale (PFO) is a common finding, complicating stroke causality assessment.
• Thorough workup is crucial to identify other embolic sources and avoid premature PFO closure.

Observation:

• A 38-year-old patient experienced recurrent vertebrobasilar strokes, initially suspected as vertebral artery (VA) dissection.
• Patent foramen ovale (PFO) was detected and closed, but strokes recurred with a persistent right-to-left shunt.
• MRI revealed a transient left VA occlusion, leading to the diagnosis of a left VA pseudoaneurysm.

Findings:

• The recurrent ischemic events were attributed to a left VA pseudoaneurysm and an anatomical variant of the right posterior inferior cerebellar artery (PICA).
• Successful coil occlusion of the pseudoaneurysm resulted in complete recovery without further strokes.
• The case underscores the importance of comprehensive stroke evaluation beyond incidental findings like PFO.

Implications:

• This case emphasizes the need for meticulous diagnostic evaluation in young stroke patients to uncover all potential etiologies.
• It highlights that patent foramen ovale (PFO) closure should not be the sole intervention if other embolic sources are suspected.
• Vascular neurologists should guide the follow-up and management of these complex stroke cases, including PFO closure verification.