APCU25MPA7 When two anomalies collide: the synergistic role of PFO and chiari network in a young woman with stroke

Introduction Cryptogenic stroke refers to an ischemic event with no clear underlying cause, despite comprehensive evaluation, accounting for up to one-third of ischemic strokes in young adults. Structural defects such as PFO (patent foramen ovale) are increasingly implicated in enabling paradoxical embolism in young stroke patients. The presence of a Chiari network, a benign embryologic remnant in the right atrium, may further enhance embolic risk by promoting right-to-left shunting or serving as a nidus for thrombus. This case illustrates the combined contribution of PFO and the Chiari network in a young woman with ischemic stroke.Case Presentation A 34-year-old woman presented with a sudden onset of right facial droop, right arm weakness, and slurred speech. Symptoms began while seated at work and partially resolved before arrival at the emergency department later. She had no vascular risk factors, no trauma, and no recent travel history. Initial imaging revealed a left frontal cortical infarct. Electrocardiography and transthoracic echocardiography were unremarkable.Results Transesophageal echocardiography with bubble contrast demonstrated a PFO with significant right-to-left shunting on the Valsalva and a Chiari network in the right atrium. No atrial fibrillation or deep vein thrombosis was detected. The stroke was classified as cryptogenic, likely due to paradoxical embolism. After a multidisciplinary review, percutaneous PFO closure with an Amplatzer device was discussed as a mainstay of treatment.Discussion This case emphasises the need to evaluate structural cardiac causes in young patients with cryptogenic stroke. PFO is a well-established risk factor for paradoxical embolism, and the presence of a Chiari network may further potentiate this risk by facilitating shunt flow or acting as a filter for thrombus. Contrast-enhanced transesophageal echocardiography remains the most sensitive diagnostic modality for detecting intracardiac shunts. Evidence from randomised trials supports closure of PFO in carefully selected patients to reduce stroke recurrence.Conclusion Young patients with cryptogenic stroke should be assessed for PFO, especially when other risk factors are absent. The Chiari network may enhance embolic potential in these cases. An interdisciplinary approach combined with appropriate intervention often yields excellent clinical outcomes.