Cryptogenic Stroke with Isolated Cranial Nerve Deficits Attributable to a Small PFO: Successful Management with Cocoon Occluder
Kalyan Munde
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Sandip Ghoti *
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Samkit Mutha
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Anant Munde
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Jayakrishna Niari
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Gaurav Kothari
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Suvarna Thorat
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Hariom Kolapkar
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Mohan Paliwal
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Anagh TS
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Khaleel Shaikh
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Vaishali Gaba
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Vighnesh Rane
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Anil Kumar Gupta
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Prasad Jain
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Divya Kantak
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Dhanlaxmi Chettiar
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
Rahul Sonawane
Department of Cardiology, GGMC and Sir JJ Hospital, Mumbai, Maharashtra, India.
*Author to whom correspondence should be addressed.
Abstract
Patent foramen ovale (PFO) is present in approximately 20–25% of the general population but is implicated in only a small subset of ischemic strokes, particularly in young adults with cryptogenic events. Stroke in individuals under 45 years accounts for only 10–15% of all ischemic strokes, and PFO-related presentations with isolated cranial nerve involvement are exceptionally rare.
We report a 40-year-old male who presented with acute slurring of speech and deviation of the mouth to the left. Neurological examination revealed dysarthria and tongue deviation without motor weakness. A thorough work-up for young-onset stroke was performed: bilateral carotid and vertebral Doppler were normal, chest radiograph was normal, antinuclear antibody (ANA) and antiphospholipid antibody (APLA) profiles were negative, homocysteine was borderline elevated, and fundus examination showed no papilledema. CT venous angiography of the lower limbs ruled out deep venous thrombosis. Magnetic resonance imaging demonstrated acute non-hemorrhagic infarcts in the right inferior frontal gyrus and right post-central gyrus. Transthoracic echocardiography with bubble contrast revealed right-to-left shunting during Valsalva, and transesophageal echocardiography (TEE) confirmed a 4-mm PFO.
Given the patient’s young age and isolated cranial nerve presentation, TEE-guided PFO closure was performed with a Cocoon 30/30 occluder device under fluoroscopic guidance, with no residual shunt post-procedure. The patient remained hemodynamically stable, developed no arrhythmia, and demonstrated marked improvement in speech function during follow-up.
This case underscores the clinical relevance of small but hemodynamically significant PFOs in young patients with cryptogenic stroke and highlights the importance of systematic etiological evaluation and timely intervention.
Keywords: Patent foramen ovale, cryptogenic stroke, young adult, dysarthria, Cocoon occluder, transcatheter closure