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
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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