Age: 30.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Activated partial thromboplastin time normal, Angiogram pulmonary normal, Anticoagulant therapy, Atrial septal defect, Beta-2 glycoprotein antibody negative
Clinical narrative: stroke (from dvt -- > PE -- > via PFO -- > stroke, disabling)  Received moderna Covid vaccinations 24 March and 22 April 2021  5/19/2021?removal of peripheral neurostimulator electrode array [left], removal of vagal nerve stimulator pulse generator (left), as they were not working to control her drug-resistant epilepsy  6/11/2021?MRI guided laser ablation of right amygdala and hippocampus  6/11/21: US doppler b/l- No evidence of acute DVT in either lower extremity.  CT angio showed right heart strain, no evidence of pulmonary hypertension, limited cardiomegaly, small vessel disease, right hemithyroidectomy  6/12/2021?postoperatively, when she was extubated?she was not able to follow commands and was found to be hypoxic.  CT head demonstrated a new right intraparenchymal hemorrhage with intraventricular hemorrhage along the surgical site. CTA chest?showed acute segmental and subsegmental pulmonary emboli throughout both lungs with additional central with pulmonary artery involvement on the right.  There are persistent findings consistent with right heart strain with RV/LV ratio 1.2, and likely evolving pulmonary infarcts. Patient was reintubated. 6/12/2021?she underwent an attempt at mechanical thrombectomy with interventional radiology but there was no significant pulmonary embolus burden and no intervention was performed.  Probable atrial septal defect or PFO was noted. She underwent IR guided IVC filter placement.  6/11/2021?6/13/2021- no anticoagulation was administered  13 June 2021 CT angio head and neck showed severe stenosis right M2, left M1, left M2, left cingulate infarct, possible medullary infarct  6//14/21: CT head- Moderate to large bilateral MCA territory infarcts greater on the left. Petechial type hemorrhage or conversion within the left basal ganglia infarct. Small anterior right cingulate gyrus infarct. Possible anterior medullary infarct.   6/14/2021?7/1/2021?prophylactic anticoagulation was started with heparin 5000 subcutaneous every 8 hours. Aspirin started on 6/14/21.   6/28/21- V/Q scan- Pulmonary embolism absent.  6/28/21: TEE- No thrombus visualized in the left atrial appendage. Demonstration of a moderate sized PFO in addition to a aneurysmal intra-atrial septum , EF 55%  7/1/2021 CT head showed evolving moderate to large bilateral MCA infarcts with petechial hemorrhage lateral left MCA, right post ablation edema with decreased hemorrhage with improvement in cerebral mass-effect. Started on Lovenox 40mg subcutaneous BID, with concern for possible antiphospholipid syndrome. She was discharged on Lovenox 40mg BID with increase to 80mg BID on 7/16/21.   Hypercoagulable work-up 6/11/2021 Factor V Leiden?negative Factor II mutation/prothrombin gene mutation?negative Antithrombin III?79%, with normal being 80% Cardiolipin IgG/IgM?negative Beta 2 glycoprotein antibodies negative Hexagonal Lupus anticoagulant?4, or negative DRVVT?1.4, increased on 11 June 2021 Protein S ?55.1%, normal Protein C?101 % normal Factor VIII activity 104% 9 INR normal and PTT normal  Fibrinogen had been slightly low at 185 CBC and renal function have been normal No family history of clotting or stroke