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Patient initials or identifier number
Relevant clinical history and physical exam
A 27-year-old woman was admitted to department of neurology with left-sided limb weakness of 8 hours duration. There was no history of atherosclerosis risk factors such as hypertension, diabetes, hyperlipidemia or smoking. A neurologic examination revealed limb weakness on the left side.
Relevant test results prior to catheterization
Brain magnetic resonance imaging showed acute infarction in the right frontal, temporal and insular regions as well as basal ganglia. Electrocardiography was normal.
Relevant catheterization findings
Cerebral angiography showed thrombi and severe stenosis (90%) of M1 segment of the right middle cerebral artery. A microcatheter was navigated across the stenosis of M1 to M2 portion of the right middle cerebral artery using a 0.014 inch microwire. After removing the microwire, a Solitaire retriever stent (4 x 20 mm) introduced through the microcatheter and fully deployed across the entire stenosis. Five minutes after deployment, the Solitaire stent retrieved without residual stenosis.
Transcranial doppler (TCD) and transesophageal echocardiography (TEE) were performed in order to ascertain the etiology of stroke. TCD showed severe right-to-left shunting (shower effect) after Valsalva maneuver and bubble test and subsequently TEE identified a 1.9 mm of tunnel-sharped PFO. The patient had suffered a paradoxical stroke associated with PFO. After 2 weeks of the stroke onset, the patient received transcatheter PFO closure. The procedure of PFO closure was performed under X-ray and transthoracic echocardiographic monitoring. After insertion of the right femoral vein sheath, a 0.035 inch super stiff guide wire advanced into the left atrium through the open for a men ovale and positioned in the upper left pulmonary vein. The 9 french, 80 cm trans septal delivery system advanced into the left atrium over the stiff wire. The Cardio-O-Fix 18/25 mm PFO occluder introduced through the delivery sheath and the left atrial disc was released by pushing it out on the left atrial side, and then the delivery sheath withdrawn to release the right atrial disc. The correct position detected by transthoracic echocardiography. There was no recurrent stroke noted at 16 months follow-up and no residual right-to-left shunting was observed in TCD.
Our case demonstrates that mechanical thrombectomy using Solitaire device and transcatheter PFO closure with Cardio-O-Fix occluder can be safely and successfully performed to treat acute paradoxical stroke.