Paul Baumert, MD

Sports Medicine Conference

July 20, 2006

      Sudden Unilateral Weakness   

•      20 yo male, previously healthy

•      Mid-season; program veteran

•      Tripped while back-peddling in practice

–  Unable to walk off playing surface

–  Stumbled to the left side

•      Reported that he felt weak

–  Especially his left leg

•      Complained of mild headache and photophobia

More History

•      No history of trauma

•      Intermittent headache for past 2 weeks

•      No dietary intake that day

•      Denies feeling ill, other ROS negative

•      PMH, PSH, Fam Hx, Medication, Allergies all benign

Examination

•      Alert, oriented but “distant and tired”

•      P 95, BP 126/70, RR 18

•      FS Glucose 106

•      Initial exam:

–   HEENT, Car, Pulm, Abdomen:  unremarkable

–   Ext: mild weakness in LLE for foot dorsiflexion, leg extension, sensory exam normal, reflexes 2+ patella and achilles

Examination

•      Over next 15 to 20 minutes

–  Dense weakness of both LUE and LLE

–  Facial muscle tone decreased on left

–  Loss of coordination of left hand and leg

•      Mood indifferent

Differential Diagnosis

•      Complex Migraine

•      Hypoglycemia- poor nutrition

•      Cerebral Vascular Event

•      Temporary Ischemic Attack

•      Vasculitis

•      Factitious presentation

Course and Results

•      Transported to local ED

–  Urgent head CT: normal

–  MRI: normal

–  CMP, CBC, Urine Drug Screen: normal

–  Sed Rate, D-Dimer: normal

–  MRA: initial report normal

•      Symptoms resolved while in MR scanner

•      Delay in reporting of MR results

Return of Symptoms

•      Symptoms returned 45 minutes later

–  More severe

•      Updated report from MRA

–  Slight irregularity in signal of Right M1 branch of the MCA, ? vasculitis

•      TPA administered

–  Symptom resolution within 20 minutes

•      Transport to parent hospital – Neuro ICU

Further Workup

•      Repeat MRI/A: resolution of filling defect

•      Echo: normal, EF 65%

•      TEE: pinpoint PFO with a small shunt

•      Stress Echo: sig. shunting at max effort

•      Venous US: normal

•      Hypercoagulation workup was negative

Diagnosis: CVA

•      Thrombotic source believed to be PFO with intermittent shunting

•      PFO persist in 25% of US adults

•      Often blamed for cryptogenic stoke

^–     Found in 39-54% of young cryptogenic stoke pts¹

^–     Recurrence rate 3.8-5.5% per year²

–   Recurrence not dependent on treatment

–   Debated by Meissner et al. in J Am Coll Cardiol 2006

Patent Foramen Ovale and Stroke

•      Medical: anticoagulation

–  Lausanne Stroke Registry, PFO in Cryptogenic Stoke Study

–  No difference in stroke recurrence between ASA and Warfarin

•      Percutaneous transcatheter closure

–  Multiple devices but not for general use

–  Surgical closure is gaining popularity

•   Follow-up limited (erosions, thrombus, no closure)

•   FDA humanitarian device exemption

Follow Up

•      Anticoagulation for 3 months

•      Repeat MRA: normal

•      Percutaneous closure (Amplatzer 25mm device)

•      Clopidogrel and ASA used for 3 months

–   ASA for 3 additional months

•      TEE at 3 months showed closure of PFO

•      Resumed non-contact activity at 3 months

•      Resumed all activity at 6 months