Transient Visual Field Disturbance In Young Volleyball Player

HISTORY: A 14-year-old female volleyball player arrived for consultation after a 3-day hospitalization due to partial visual field loss, followed by general weakness and headache, which occurred during a training warm-up. She reported having similar events several times during the previous year, with milder symptoms lasting a few minutes and resolving spontaneously. She also mentioned that her mother suffers from migraines without aura. Investigations during hospitalization revealed normal physical, neurological and ophthalmologic exams. Resting ECG demonstrated a few episodes of second-degree Type 1 atrioventricular (AV) block (Wenckebach). Blood tests were normal. PHYSICAL EXAMINATION: The patient has a tall and thin build, hand span/height: 1.01 Weight: 66.1 kg, Height: 180.5 cm, Pulse: 72 BPM, Blood Pressure: 98/58 mmHg. Normal heart sounds with no murmurs, both laying and during standing. Normal and symmetrical femoral pulses. No neurological deficits, Normal eye examination. No other abnormal findings were noted. DIFFERENTIAL DIAGNOSIS: Migraine with aura Embolic events Brain vascular malformations or other anatomical pathology TESTS AND RESULTS: Echocardiogram: Small atrial septal defect (ASD) with left-to-right shunt, mildly dilated right atrium and ventricle, and flattening of the septum during diastole. 24-Hour Holter ECG: Dominant sinus rhythm (45-145 bpm, average 74 bpm), rare ventricular premature beats, and intermittent Wenckebach AV block, particularly in the late evening and during the night. Brain MRI: within normal limits. Cardiac MRI: Pending results. WORKING DIAGNOSIS: Migraine with visual field disturbance aura Asymptomatic small ASD with left-to-right shunt, mild dilation of the right atrium and ventricle, associated with a very low risk of embolism. Periodic Wenckebach AV block TREATMENT AND OUTCOME: Migraine with aura was confirmed by a pediatric neurologist as the most likely diagnosis. The patient was advised to follow up and use pain relievers (NSAIDs, acetaminophen) for headache management. She was cleared to participate in physical activity and gradually resumed full training participation. At her one-month follow-up, two more events were reported, both occurring outside of training and relieved by painkillers. The results of the cardiac MRI are still pending.