May-Thurner syndrome (MTS), also referred to as iliac vein compression syndrome, occurs when the iliac venous structures are compressed by iliac arterial structures against the underlying bony architecture [1,2]. In this case report, we report an embolic stroke in the setting of MTS and with a patent foramen ovale (PFO). CASE PRESENTATION:A 44 year old hispanic male with no significant past medical or surgical history presented with an abrupt onset of expressive aphasia that lasted for about one hour. At the time of evaluation, his symptoms had resolved. The patient otherwise denied any weakness, sensory loss, headaches, vomiting, nausea, twitching, decreased level of alertness, or hemibody/hemifacial numbness or tingling sensation. He did not meet criteria for IV tPA or any neurovascular intervention. He does not consume tobacco, alcohol, or use illicit drugs. He denied any family history of hypercoagulable disorders. Head computed tomography (CT) did not demonstrate hemorrhage and CT perfusion of the head and neck did not demonstrate any lesions or flow defects. The magnetic resonance imaging (MRI) revealed a left frontal lobe acute ischemic stroke. Cardioembolic work up was pursued. A transesophageal echocardiogram showed evidence of a positive bubble study and PFO. His Risk of Paradoxical Embolism (ROPE) score was calculated to be 8. To determine the origin of the embolism, venous ultrasound of the lower extremities was performed and demonstrated no signs of deep vein thrombosis. Furthermore, magnetic resonance venography (MRV) of the pelvis demonstrated narrowing of the left common iliac vein between the right common iliac artery and lumbar spine, consistent with MTS. It was concluded that the patient would require a PFO closure followed by catheter-based venogram with intravenous ultrasound (IVUS) of pelvic vasculature to confirm the diagnosis. IVUS demonstrated a 24% reduction in area of the left common iliac vein and 76% reduction in area of the left external iliac vein. He was treated with balloon venoplasty of the left external/common femoral vein as well as stent placement in the left external/common iliac vein. DISCUSSION:In patients aged 40-50: the rate of ischemic strokes doubled, 1 in 4 have MTS, and 1 in 5 have a PFO [1, 2, 3]. The combination of MTS and PFO can produce disabling consequences for patients. Therefore, proper clinical judgment should be used to determine the necessity of further imaging modalities. As in the case above, in a young male with no risk factors further invasive imaging should be performed to ensure proper diagnosis and management to prevent further disabling sequelae. CONCLUSIONS:In patients with no risk factors presenting with stroke symptomatology, proper imaging modality apart from lower extremity venous ultrasonography should be considered. The gold standard is catheter based venography to diagnose MTS.