Pediatric Stroke Due to Thromboembolism Secondary to Prominent Eustachian Valve With Patent Foramen Ovale

BACKGROUND: Pediatric strokes can occur from diverse causes, and thromboembolism can occur paradoxically in cardiac defects with right-to-left shunt, leading to stroke. CASE SUMMARY: An 8-year-old boy presented to the pediatric emergency unit with sudden-onset right-sided stroke after a Valsalva maneuver. Neuroimaging revealed a left middle cerebral and middle cerebral-anterior cerebral watershed infarct with a thrombus in the proximal internal carotid artery. Cardiac evaluation showed a coexisting large persistent Eustachian valve and patent foramen ovale (PFO). He was started on aspirin and other supportive measures. He underwent an elective closure of the PFO. DISCUSSION: A PFO can develop a right-to-left shunt during a Valsalva maneuver, causing paradoxical embolism of right heart system clots. Though treated medically, certain criteria, including presence of a large Eustachian valve, may warrant closure of the defect. TAKE-HOME MESSAGES: Cardiac thromboembolism should be considered in any sudden-onset pediatric cryptogenic strokes, especially after a Valsalva maneuver such as lifting a weight. Treatment strategies may differ from other strokes and may involve repair of the cardiac defect. This decision should be individualized for each pediatric case.