Lifestyle may warrant PFO closure
No previous studies have considered occupation or hobbies as an indication for PFO closure in patients with CS. Our patient’s active lifestyle, particularly his scuba diving and participation in contact sports, made him a poor candidate for anticoagulation. Scuba diving is associated with decompression sickness and air emboli, which can be a mechanism of cerebral ischemia, especially in patients with a right-to-left shunt, such as with PFO.9
We did not observe a strong temporal relationship between diving and stroke in our patient. MRI findings suggested that he had multiple minor embolic events over time, which is consistent with a prior case report.9 This suggested air emboli as a possible source of stroke, in which case, our patient might not benefit from antiplatelet or anticoagulation therapy.
THE TAKEAWAY
This case illustrates the importance of a thorough social history and knowledge of the patient’s hobbies, occupation, and preferences in evaluating and treating individuals with CS associated with PFO. The current literature does not provide complete answers to the cause, diagnosis, and management of CS; additional research is needed.
The work-up involved in defining the etiology of stroke includes, but is not limited to, head and brain imaging, an echocardiogram, hypercoagulability tests, and vascular imaging. The work of Sanna et al showed that approximately 12% of patients with CS have atrial fibrillation when monitored over a one-year period, suggesting atrial fibrillation as a possible cause in some cases.10
As the case described here demonstrates, further research is warranted regarding how a patient’s occupation and lifestyle factor into decision-making for patients with PFO.