To report a patient with spinal cord infarction due to paradoxical embolism secondary to patent foramen ovale complicated by May Thurner syndrome. 

Spinal cord infarction (SCI) is rare, accounting for 1-2% of ischemic strokes. SCI in adults is often secondary to aortic disease/surgery or spinal disease. There is limited literature regarding associations between SCI and patent foramen ovale (PFO) and/or thromboembolic syndromes such as May Thurner syndrome.

Case report.

A 33-year-old previously healthy gentleman presented with acute onset bilateral leg weakness. CT head, CTA head/neck showed no evidence of intracranial hemorrhage or infarct. Subsequently, CT spine imaging was performed without evidence of spinal hemorrhage. IV Tenecteplase was administered due to concern for acute ischemia. Initial MRI brain/spine were unrevealing. However, repeat MRI spine performed 48 hours later was notable for diffusion and T2/FLAIR signal abnormalities involving the central gray matter at T11-12 level suggestive of SCI.

CTA of the abdomen/pelvis did not identify aortic pathology. Serum thrombophilia work-up was unremarkable, besides elevated serum D-dimer. Venous ultrasound of all four extremities demonstrated superficial venous thrombosis of the right medial cubital vein, without evidence of deep vein thrombosis. MRA abdomen/pelvis was notable for May Thurner syndrome with compression of left iliac vein by right common iliac artery. Transesophageal echocardiogram was notable for PFO with atrial septal aneurysm. The patient’s RoPE (Risk of Paradoxical Embolism) score was 8, indicating 84% likelihood that stroke was secondary to PFO in setting of paradoxical embolism due to venous thromboembolism from May Thurner syndrome.

 Patient was discharged on aspirin 81 mg and atorvastatin 80 mg with plan for cardiac monitoring and follow up with structural cardiology for PFO closure.

Paradoxical embolism from PFO and venous thromboembolism should be considered as an etiology for SCI, particularly in younger adults lacking more common aortic or spinal disease risk factors.