Deep Decisions: Navigating Stroke Risk And Safe Diving In A Patient With Patent Foramen Ovale And History Of Decompression Illness

HISTORY: Twenty-five years ago, a 17-year-old healthy, right-handed male presented with right hemiparesis and sensory loss after scuba diving. The patient descended to 37 meters and ascending following typical dive safety protocol. Upon reaching the dive boat, he had a seizure and lost consciousness. Upon regaining consciousness, he noted new onset right-sided hemiplegia and hemiparesis. Due to the remote dive location, it took four hours to reach the nearest medical center. PHYSICAL EXAMINATION: Right-sided hemiparesis and sensory loss to light touch. Regular rate and rhythm without murmur. DIFFERENTIAL DIAGNOSIS: Decompression illness. Cardioembolic stroke from atrial fibrillation. Ischemic stroke from cerebrovascular disease. Epilepsy complicated by Todd’s Paralysis TEST AND RESULTS: Cerebrovascular imaging revealed stroke and spinal cord injury with normal cerebral vessels. Transesophageal echocardiogram (TEE) demonstrated a patent foramen ovale (PFO) with a right-to-left shunt and normal biventricular function. ECG was without atrial fibrillation FINAL WORKING DIAGNOSIS: Stroke and spinal cord injury due to decompression illness TREATMENT AND OUTCOMES:100% oxygen and one week of recompression therapy were administered. Extensive physical therapy partially improved his paralysis and paresthesia. However, diminished strength (4/5) and light touch sensation (1/2) in his right leg persisted. Despite recommendations to stop diving, the patient continued to dive at shallow depths (4.5 to 6 meters). Twenty-five years later, the patient was referred by his primary care provider to cardiology to discuss the safety of scuba diving. Repeat TEE demonstrated PFO with moderate right-to-left shunt as well as atrial septal aneurysm, normal biventricular function and mild right ventricular enlargement. Cardiac CT revealed normally connected pulmonary veins. The patient’s PFO anatomy was amenable to percutaneous closure. Given his history of decompression illness, percutaneous closure was considered to decrease the risk of adverse events associated with scuba diving. After a shared decision-making discussion, the patient elected against closure of his PFO and continues to dive recreationally at shallow depths.