Endovascular Thrombectomy in a Young Female Patient With Atrial Septal Defect: A Case Report

Large vessel occlusion (LVO) in a young patient aged less than 30 years of age is greatly rare. When approaching stroke-like symptoms in younger generations, stroke mimics like epilepsy, chronic subdural hematoma, spinal cord nerve compression due to herniation of disk, or autoimmune neuropathy like Guillain-Barré syndrome or multiple sclerosis are definitely a great hindrance to rapid diagnosis. This condition is likely to increase the difficulty of accurate diagnosis and delay treatment for a stroke in combination with the rarity of strokes in young individuals. What is more, a delayed medical approach for autoimmune neuropathy, like massive steroid injection, could result in a worse prognosis. Oral contraceptives (OC) for migraine without aura are controversial for an increased risk of ischemic stroke. We experienced a highly instructive case of a young LVO patient for whom mechanical thrombectomy was performed. A 26-year-old female patient with a past medical history of migraine or depression had been transferred to the hospital complaining of left upper and lower limb paralysis. Magnetic resonance imaging showed right middle cerebral artery occlusion and cerebral infarction in the basal ganglia. Rapid endovascular thrombectomy was performed and resulted in thrombolysis in cerebral infarction (TICI) 3 by three passes. The patient was discharged without any neurological deficit on the 10^th day after admission. She was on OC pills in the last six months before the onset of symptoms. The value of D-dimer on admission was 3.9 mg/dl. We could not acknowledge the other stroke risk factors and suspected the paradoxical embolism as a mechanism of stroke, considering the patient's young age. Transesophageal echocardiography revealed a relatively wide atrial septal defect (ASD). The diagnosis of paradoxical embolism via ASD was made, and a direct oral anticoagulant was started. Closure for ASD was planned. A few months after the ASD closure, the anti-coagulant agent is planned to be ceased. Clinicians have to note that even young people with psychological disorders or migraine can suffer from LVO. More prudent prescription of OC pills for migraine patients is necessary.