May-Thurner Syndrome (MTS) refers to a venous outflow syndrome in the iliocaval territory secondary to extrinsic compression. DVTs can occur and there have been reports of arterial ischemic strokes if there is a coexisting patent foramen ovale (PFO).

A 22-year-old right-handed woman with a history of migraine with aura presented to an outside hospital after being found on the floor, somnolent, disoriented and incontinent of urine. In the emergency department her exam was notable for marked improvement in level of alertness, presence of a left gaze preference, right hemiparesis, aphasia and dysarthria. Her NIH stroke scale was 15 and vital signs were normal. Head CT was notable for a hyperdense left MCA sign; CTA of the head and neck was motion degraded. A stat MRI and MRA revealed multifocal, acute infarcts in the left MCA territory as well as occlusion of the distal left M1 segment. 

She was brought to our facility for thrombectomy. Angiography was performed and revealed a patent left MCA. Further evaluations were consistent with a PFO, absence of DVTs, though MRA of the pelvis was notable for 70% stenosis of the left common iliac vein between the right common iliac artery and the spine. Her neurologic exam was notable for subtle right-hand weakness as well as both receptive and expressive aphasias. Approximately one week after discharge she re-presented with horizontal diplopia and vertigo, which spontaneously resolved. CTA of the neck revealed a large segment dissection of the right V2. A hypercoagulable evaluation was negative, and a 30-day event monitor did not reveal any concerning arrythmias, therefore her PFO was closed. 

In contrast to prior case presentations, we have followed this patient for one year after initial presentation and have hypothesis-generating data suggesting factors underlying MTS may do the same for systemic vasculopathies or vasculitides.