Shaky Septum A case of bilateral Cerebrovascular accident in a young healthy male

bull Transient ischemic attackcerebrovascular accidents(TIACVA) are common encounters in hospitals

bull Studies such as computerized tomography (CT) scanmagnetic resonance imaging (MRI) carotid arteryDoppler transthoracic echo (TTE) and transesophagealecho (TEE) are routinely done to assess and treat theacute condition Cardiac conditions such as atrial septaldefect atrial fibrillation and atrial flutter are frequentlyassociated with TIACVA

bull We present a case of CVA in a young male incidentallyfound to have an atrial septal aneurysm (ASA) on atransesophageal echo (TEE) despite transthoracic echo(TTE) being negative

A healthy 53-year old male presented with 5 hour history of aphasia and right upper and lower extremity weakness His National Institutes of Health Stroke Scale was 17 Computerized Tomography (CT) scan of the head revealed an acute left middle cerebral artery (MCA) CVA Cerebral perfusion scan did not show any salvageable penumbra or retrievable clot 81mg Aspirin and 40mg Atorvastatin were initiated Even though electrocardiogram was negative for arrhythmias Magnetic resonance imaging (MRI) revealed left MCA infarct with multiple acute bilateral lacunar infarcts TTE only showed stage I diastolic dysfunction but his TEE showed a large ASA with about 2 cm excursion and small right to left shunt Warfarin-heparin bridge was initiated as ASA increases the risk of thromboembolic events During hospital stay he had a hemorrhagic conversion of his ischemic stroke so warfarin was held Once repeat head CT confirmed a stable hemorrhagic infarct his aspirin was discontinued and warfarin was resumed as benefits outweighed the risks He was discharged on warfarin with goal INR of 2-3

bull This is a case of left MCA infarct with multiple acutebilateral lacunar infarcts suggestive of cardioembolicetiology

bull TEE detected ASA with a tiny shunt despite TTE beingunremarkable There is limited data available on ASA asa potential cause of acute CVA

bull ASA is a congenital deformity of the inter-atrial septumconsisting of mobile tissue in the region of fossa ovaliswith phasic excursions

bull ASA with excursions gt10 mm are at 8x higher risk ofCVA than lt10 mm

bull Concomitant Patent Foramen Ovale and ASA has higherrisk of CVA than isolated etiologies

bull Treatment includes life-long anticoagulation and ifnecessary surgical repair

bull In summary for patients presenting with CVA with nosignificant risk factors a normal TTE should notundermine the value of TEE in assisting to diagnoseuncommon etiologies like ASA

bullCabanes L Mas J L Cohen A et al Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age A study using transesophageal echocardiography Stroke 199324(12)1865ndash1873 doi 10116101str24121865 [PubMed] [CrossRef] bullPearson AC Nagelhout D Castello R et al Atrial septal aneurysm and stroke A transesophageal echocardiographic study J Am Coll Cardiol 1991181223-9 [Crossref][PubMed]bullAgmon Y Khandheria B K Meissner I et al Frequency of atrial septal aneurysms in patients with cerebral ischemic events Circulation 199999(15)1942ndash1944 doi 10116101cir99151942 [PubMed] [CrossRef] [Google Scholar]bullMuumlgge A Daniel W G Angermann C et al Atrial septal aneurysm in adult patients A multicenter study using transthoracic and transesophageal echocardiography Circulation 199591(11)2785ndash2792 doi 10116101cir91112785 [PubMed] [CrossRef] [GoogleScholar]bullMattioli AV Aquilina M Oldani A Longhini C Mattioli G Atrial septal aneurysm as a cardioembolic source in adult patients with stroke and normal carotid arteries A multicentre study Eur Heart J 200122261ndash268 doi 101053euhj20012293 [PubMed][CrossRef] [Google Scholar]

Urmil Patel MD Amulya Dakka MD Merchant Yatish MD

AB Atrial septum bulging into the right atrium

A) Left MCA hypodensity suggesting infarctB) Left MCA hemorrhagic conversion

A

A

A

B

B