Dental surgery reveals a vascular anomaly

A right-to-left shunt is thought to be caused by a patent foramen ovale - or was it?

Michelle is 59 and has a past history of a transient ischaemic attack (TIA) 10 years ago.

She presents to ED with headache, vomiting, and right retro-orbital pain. She is systemically well with no signs of meningism.

Further history reveals a constellation of subtle subacute neurological symptoms, including non-specific speech disturbance, left arm inco-ordination and altered left lower limb sensation.

Three weeks ago she had dental surgery to drain a left maxillary abscess. The previous TIA is her only significant past medical history.

She does not smoke and is not on regular medications. She has not travelled recently and has no sick contacts.

Examination

On examination, Michelle is afebrile.

Neurological examination reveals a left upper limb dyspraxia and reduced co-ordination in the left lower limb.

Tone, power and reflexes

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