CHEST Guidelines-Wake-Up-Right-Sided-Hemiparesis-and-Dysarthria-in-

Wake-Up-Right-Sided-Hemiparesis-and-Dysarthria-in-

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This is a summary of a clinical case involving a 57-year-old man who presented with wake-up right-sided hemiparesis, dysarthria, and hypoesthesia, indicative of an ischemic stroke, with a National Institutes of Health Stroke Scale score of 7. The patient, obese and a heavy snorer, had a history of thrombophlebitis and a family history suggestive of thrombophilia, with deaths due to pulmonary embolism.<br /><br />A CT scan confirmed an ischemic stroke in the left temporal and insular lobes. Subsequent diagnostic tests revealed bilateral deep vein thrombosis (DVT), a patent foramen ovale (PFO), and a subtotal occlusion of both pulmonary arteries, indicative of a pulmonary embolism. Polysomnography confirmed severe obstructive sleep apnea (OSA), featuring prolonged apnea associated with oxygen desaturation events. Genetic screening identified a heterozygous mutation in the antithrombin III (ATIII) gene, leading to its deficiency—a known risk factor for DVT and embolism.<br /><br />The pathogenesis of the stroke was attributed to the interaction of three conditions: PFO, ATIII deficiency, and OSA. The OSA caused increased pressure in the right atrium during obstructive apneas, leading to a right-to-left shunt across the PFO and resulting in paradoxical embolism and stroke.<br /><br />The patient underwent treatment with IV heparin, ATIII replacement, oral anticoagulation, and continuous positive airway pressure (CPAP) therapy. Percutaneous closure of the PFO was also performed. On discharge, the patient's condition had improved significantly.<br /><br />The case illustrates the complex interaction between OSA, PFO, and thrombophilia, highlighting the risk of cryptogenic stroke in such patients. The study underlines the importance of integrated treatment strategies combining anticoagulation, respiratory support, and, when appropriate, surgical intervention in managing these conditions.

Keywords

ischemic stroke

obstructive sleep apnea

patent foramen ovale

antithrombin III deficiency

deep vein thrombosis

pulmonary embolism

paradoxical embolism

thrombophilia

continuous positive airway pressure

integrated treatment strategies