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Up to 40% of ischemic strokes have no known cause (cryptogenic). The prevalence of persistent foramen ovale (PFO) amongst patients with cryptogenic stroke (CS) is twice as high as that of the normal population, therefore suggesting a causal relationship between the two entities. However, PFO by itself is not sufficient to cause stroke, as an embolic source is needed. This source is often unknown, making the causal relationship between CS and PFO hard to demonstrate. The most frequent, although still seldom, identifiable cause of embolism in an otherwise cryptogenic stroke associated with PFO is a deep venous thrombosis (DVT) of the lower extremities. Here, we present a unique case of brachiocephalic venous DVT associated with PFO and ischemic stroke in a young patient. As the search for DVT in patients with PFO and stroke is often limited to the lower extremities, this case may suggest that an unspecified number of DVTs are overlooked. Our report lends support to paradoxical embolism as a mechanism of stroke in patients with PFO and does, at least in selected cases, suggest a more detailed search for DVT beyond the lower extremities.

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, a 68-year-old right-handed man presented hours after acute onset of left hand and leg weakness. During a 6-week period preceding admission he had experienced at least 2 sudden onset episodes of an isolated paresthesia of the left ring finger. Each persisted for approximately 2 minutes and the patient did not seek medical attention for it. He had a history of hypertension and hyperlipidemia, but no previous stroke. Clinical examination showed mild left hemiparesis, symmetric monosynaptic reflexes, and hypesthesia of the left hand, this time affecting all fingers. There were no signs of peripheral nerve lesion-sensitive or motor-and no change of or new paresthesia under provocation tests for entrapment neuropathies. MRI of the head and neck with diffusion-weighted sequences and angiography showed isolated right middle cerebral artery (MCA) stenosis and multiple acute infarctions in its watershed territories, involving the right corona radiata and cortical and subcortical white matter of the right fronto-parieto-occipital lobes (figure, A). Routine blood tests, chest radiography, ECG, long-term ECG, and EEG were normal. Transthoracic echocardiogram indicated beginning hypertensive heart disease, no cardiac thrombus or valvular dysfunction. The following day, he received successful angioplasty and stenting of the symptomatic MCA stenosis (figure, B and C). Treated before publication of the SAMMPRIS 1 trial data, follow-up of this patient to date is without further ischemic events or complications under antiplatelet therapy. Cerebral watershed infarcts typically involve the junction of the distal fields of the nonanastamosing territories of the anterior cerebral artery (ACA), middle cerebral artery, and posterior cerebral artery and account for approximately 10% of cerebral ischemias. 2 Untreated MCA stenosis is associated with a high rate of stroke recurrence 3 and warning TIAs are common. 3 Recognized pathogenetic factors are hemodynamic impairment and microembolism. 2 We report a case of unilateral watershed infarction due to MCA stenosis with prodromal isolated paresthesia of 1 ring finger. Pseudoperipheral sensory-motor deficits due to CNS lesions were described as early as 1909. 4 In a more recent MRI study on cortical infarction with weakness restricted to particular groups of fingers, 5 predominant ulnar finger involvement was closely