A 33-year-old male has been admitted under the stroke physicians with an episode of transient left upper limb weakness, which lasted 1 hour after exercising at the gym. He has no prior medical history. He is a lifelong non-smoker with no important family history. He is very fit and plays competitive basketball. Blood tests reveal total cholesterol of 4.3 mmol/L. BP is 110/70 mmHg and ECG shows sinus rhythm with normal morphology. The stroke physicians arrange a CT head and echocardiogram. The CT head returns normal. You are asked to comment on the echocardiogram report which documents a structurally normal heart with no thrombus in the LA. The only finding is of an ‘aneurysmal’ intra-atrial septum.
What should you advise the stroke team?a. The patient should have a TOE as transthoracic echocardiography cannot rule out a cardiac source of thrombus
The case describes a young patient without any risk factors for cardiovascular disease who clinically has had a TIA. In these patients a paradoxical embolus via a PFO should be considered. ‘Aneurysmal’ intra-atrial septum describes an excessively mobile septum (septal excursion ≥10 mm with a base diameter ≥15 mm on echo). Aneurysmal intra-atrial septums commonly have associated PFO or fenestrations, and so the possibility of a communication should be suspected if seen on echo. PFO with an aneurysmal septum confers a higher risk of stroke then PFO alone. A well-performed bubble contrast echocardiogram (with sniff and Valsalva) is the investigation of choice to confirm the presence of a right-to-left shunt at atrial level.