A CASE REPORT OF RECURRENT EMBOLIC STROKE EVENTS AFTER PFO CLOSURE IN A YOUNG PATIENT

초록

Background and Aims: We present a case with recurrent embolic stroke even after PFO closure. Methods: A 20-year-old man presented with sudden sensory aphasia. Brain MRI showed acute Lt MCA cortical infarction with Lt proximal M2 occlusion suggesting embolic thrombus. He had been taking clopidogrel for previous stroke in Lt postcentral gyrus 2 years ago. Echocardiography showed large PFO (>2mm) with right to left shunt and hypermobile septum suggesting high risk PFO and his RoPE score was 10. Holter and laboratory findings were negative. Results: PFO closure was done, but 2 years later he had a recurrent stroke in Lt MCA cortex. We started implantable loop recorder and added Edoxaban with clopidogrel. 1 year later, 4th attack with aphasia occurred, Lt MCA cortical lesion was found. We changed Edoxaban to Rivaroxaban. ILR findings were negative for 28months and no pulmonary AV fistula was revealed on chest CT. After 2 years, he presented with visual discomfort, and brain MRI confirmed Rt PCA territory infarction. He has been taking clopidogrel and rivaroxaban, with good adherence. Echocardiography indicated suspicious observation of potential thrombi around the closure device or the presence of microbubbles suggesting a residual shunt. Based on these findings, the treatment regimen was revised to include aspirin and warfarin. No new-onset AF after PFO closure was observed on 3-days Holter. No abnormalities were observed on autoimmune tests. Conclusions: This case underscores the clinical challenges and complexities in managing recurrent embolic stroke in a young patient with PFO closure, highlighting the critical need for individualized treatment plans in preventing stroke recurrence.