Unusual Cause of Stroke in a Middle-Aged Woman

INTRODUCTION Many ischemic strokes are considered cryptogenic as they occur without a well-defined etiology. However, uncovering the pathophysiology affects prognosis, outcome, and management. The Trial of Org 10172 in Acute Stroke Treatment (TOAST) began classifying ischemic strokes as large-artery atherosclerosis, cardioembolic, small-vessel occlusion, stroke of other determined etiology, and stroke of undetermined etiology.1 Twenty-five to forty percent of ischemic strokes are considered cryptogenic strokes, which are diagnosed through exclusion. The Northern Manhattan Study showed that the prevalence of cryptogenic strokes was higher in African Americans and Hispanics than in Caucasians.2 No clear risk association has been found for age and gender.3,4 Multiple mechanisms have been proposed for cryptogenic strokes such as cardiac embolism secondary to atrial fibrillation, paradoxical embolism through a cardiac septal defect, undefined thrombophilia, and sub-stenotic cerebrovascular disease.5 However, there are other important and unidentified mechanisms to uncover. This case study describes a middle-aged woman who presented for an ischemic stroke and was found to have a stenosis of the brachiocephalic vein, likely secondary to chronic pleurisy or congenital malformation.