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Título

REVERSIBLE ISCHEMIC NEUROLOGICAL DEFICIT CAUSED BY S-PROTEIN DEFICIENCY ASSOCIATED WITH THE PRESENCE OF PATENT FORAMEN OVALE: A CASE REPORT

RESUMO

CASE PRESENTATION: K.R.G.R., a 36-year-old female patient presented with sudden aphasia, dyslalia and acalculia. She had complete remission of these symptoms in about 10 hours, but remained verbalizing with paraphasia for more than a week, and then evolved completely asymptomatic. The adopted conduct was, in the first two weeks, treatment with acetylsalicylic acid 300mg a day, request for investigation tests (electrocardiogram, Holter, transthoracic echocardiogram, transesophageal echocardiogram, Doppler of the carotid and vertebral arteries, chest X-ray in PA and profile and cranial MRI) and ambulatory monitoring of blood pressure. Serum tests revealed a protein S deficiency and presence of hyperactivated factor VIII, possibly related to the use of oral contraceptives. The conclusion is that the patient had suffered a left parietal cerebral ischemia, with remitted deficit, caused by an embolism originating from a state of transitory hypercoagulability and favoured by the presence of a patent foramen ovale(PFO), confirmed by echocardiography. The patient started oral anticoagulation with warfarin 5mg a day, and started using an IUD, no longer using oral contraceptives, with normalization of protein S and factor VIII. Afterwards the PFO was surgically occluded, and she started taking acetylsalicylic acid 100mg a day. DISCUSSION: Protein S is a cofactor for the cleavage of coagulation factors Va and VIIIa and its deficiency predisposes to the formation of venous or arterial thrombi, which when moving lead to the possibility of ischemic strokes. When the phenomenon lasts beyond 24 hours with subsequent improvement it is said to be a reversible ischemic neurological deficit. Another possible etiology for an ischemia is the persistence of communication between the cardiac atria, especially when there is considerable size of this communication, a large amount of shunt between the chambers and the presence of an aneurysm or redundant membrane in the interatrial septum. FINAL COMMENTS: The association of diverse etiological pathways may be understood as being of importance, both for sharing the study, as well as for analysing the evolution of this patient profile and choosing the best conducts to be taken, since treatment ends up necessarily developing on two distinct fronts: anticoagulant drug therapy and surgical intervention.