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Abstract Details

PFO and Push-Ups: A Case Series of Valsalva Before Cryptogenic Stroke
Cerebrovascular Disease and Interventional Neurology
P6 - Poster Session 6 (12:00 PM-1:00 PM)
One proposed mechanism of cryptogenic stroke (CS) is via a patent foramen ovale (PFO), which can serve as a conduit for paradoxical embolus or as a nidus for thrombus formation within the conduit itself. Herein presented is a case series describing four individuals with CS following or during activities that involved Valsalva-like-straining; each was subsequently found to have PFO with severe right-to-left shunting, exacerbated by Valsalva. These observations may suggest a previously undescribed association for CS patients with PFO.
Case 1, a 20-year-old male, presented with aphasia upon waking after intense weightlifting late the previous evening. Case 2, a 34-year-old US-Army-service-woman, presented with left-sided weakness and hemianopsia during push-ups. Case 3, a 49-year-old male, presented with right hemiparesis and partial aphasia just after he had been doing push-ups and bench pressing 300lbs in quick succession. Case 4, a 60-year-old male with hypertension presented with diplopia, right hemiparesis, and dysarthria shortly after intense lifting of heavy boxes. Acute infarctions were confirmed on MRI Brain for all patients. RoPE scores were 9, 8, 8, and 3 respectively. Echocardiogram demonstrated a medium-large sized PFO with moderate R-L shunting at rest and severe shunting with Valsalva in all cases; Case 4 additionally had an atrial septal aneurysm. Shunting was considered severe when microbubbles in the left atrium were too numerous to count within three cardiac cycles. Cases 2-3 ultimately underwent PFO closure.
The authors suspect Valsalva-like-straining may have led to the hemodynamic conditions for paradoxical embolism in four patients with CS and PFO. Recent clinical trials have shown benefit of percutaneous PFO closure in select patients with high-risk PFO features. Future screening tools selecting CS patients for PFO closure may warrant the inclusion of high-risk PFO features and, possibly, a “Valsalva-provocation” question. Additional studies are needed to validate this association.
Elle Wade, MD
No disclosure on file
Martha Robinson, MD (Steward Health Physician Services) Dr. Robinson has nothing to disclose.
Atul Singla No disclosure on file
Justin A. Salerian, MD (Tulane University, School Of Medicine, Department of Neurology) Dr. Salerian has nothing to disclose.