Recurrent cerebral infarctions in a young patient with migraine and patent foramen ovale rapidly progressing to severe vertebrobasilar artery stenosis with partial occlusion within 12 weeks: a case report

The etiology of ischemic stroke in young adults is complex and requires dynamic reassessment as the disease course evolves. We report an 18-year-old woman with migraine with aura. She initially presented with multiple posterior circulation infarctions and was found to have a patent foramen ovale (PFO) with a moderate right-to-left shunt. The infarctions recurred the day after cervical and cranial manipulation. Within 12 weeks, the condition progressed to severe stenosis and partial occlusion of the V3-V4 segments of the left vertebral artery, the basilar artery, and both posterior cerebral arteries. High-resolution vessel wall imaging (HR-VWI; 3D-VISTA sequence) showed eccentric wall thickening and intramural hematoma, supporting vertebrobasilar artery dissection. After individualized antithrombotic and conservative treatment, wall thickening and luminal stenosis partially improved during 11 months of follow-up, with no new infarction. This case suggests that vascular imaging should be repeated when the clinical course of stroke in a young patient is inconsistent with the initial assessment, with HR-VWI performed when necessary. A single case cannot establish a causal relationship between cervical manipulation and arterial dissection or the efficacy of any specific treatment.