turner syndrome ( ts ) is caused by partial or complete monosomy of the x chromosome .
only a few cases of ts with ischemic stroke have been reported [ 2 , 3 , 4 , 5 ] . in previously reported cases , various arteriopathies affecting the cerebral arteries such as fibromuscular dysplasia , hypoplasia , moyamoya syndrome , and
, we report a case of ts with multiple embolic infarcts caused by a cryptogenic embolism .
a 28-year - old woman with ts was referred to our hospital because of abnormal findings on brain magnetic resonance imaging ( mri ) .
she was diagnosed with ts [ karyotype : 45 , x/46 , x , + mar ] at the age of 16 years due to amenorrhea .
she denied alcohol , tobacco , or drug use and had no family history of neurologic disorders .
the patient was afebrile with a blood pressure of 180/130 mm hg and a heart rate of 89 beats / min .
she was obese with a body mass index of 27.3 kg / m ( 160 cm height , 70 kg weight ) .
she visited hospital due to sudden - onset severe headache with high blood pressure ( 240/140 mm hg ) .
she underwent brain computed tomography and mri at the referring hospital for differential diagnosis of thunderclap headache including hypertensive intracranial hemorrhage , subarachnoid hemorrhage , arterial dissection , or reversible cerebral vasoconstriction syndrome .
brain computed tomography was unremarkable , but diffusion - weighted imaging showed restricted diffusion in multiple lesions involving multiple vascular territories ( fig 1a ) .
cerebral magnetic resonance angiography ( mra ) ( fig 1b ) and carotid sonography demonstrated no extracranial or intracranial arterial stenosis .
laboratory tests revealed diabetes mellitus ( fasting plasma glucose 219 mg / dl , hemoglobin a1c 11.0% ) and hyperlipidemia ( low - density lipoprotein 189 mg / dl ) .
transthoracic echocardiography revealed normal valvular structure and function with a normal left ventricular ejection fraction .
patent foramen ovale , atrial septal aneurysm , or any aortic pathologies including aortic atheroma were not detected in transesophageal echocardiography .
the results of the hypercoagulability panel , vasculitis panel , and cerebrospinal fluid examination were all negative .
aspirin was administered , and medications for hypertension , hyperlipidemia , and diabetes were also started . within few hours after blood pressure control ,
the patient was discharged from the hospital without any symptoms of stroke , and recurrence was not observed in the 2 years after discharge .
cerebrovascular arteriopathies such as fibromuscular dysplasia , congenital hypoplasia , moyamoya syndrome , and premature atherosclerosis   have been shown to be causes of ischemic stroke in previous case reports . in this case
furthermore , our patient showed multiple lesions in different vascular territories that were strongly suggestive of embolic stroke .
atrial fibrillation ( af ) could also be considered a potential source of embolic stroke in ts , as p - wave dispersion , a potential substrate for af , is increased in ts .
the classical risk factors for developing af include hypertension , diabetes mellitus , and valvular disease , and these are more common in ts than in the general population .
however , we could not completely exclude the possibility of paroxysmal af , as holter monitoring has a low yield for af detection ( 35% ) .
other possible cardio - aortic sources of embolism include intracardiac shunts , thrombi , calcifications / vegetations in the mitral valve , or aortic atheroma plaque .
we sought to identify possible cardio - aortic sources on transthoracic echocardiography , transesophageal echocardiography , and transcranial doppler shunt test ; however , all tests were negative .
some case reports have described deep venous thrombosis and portal vein thrombosis in ts [ 11 , 12 ] .
these factors include fibrinogen , d - dimer , factor viii , von willebrand factor , and proteins c and s .
we also considered the possibility of hypercoagulability as a cause of stroke in this case ; however , levels of d - dimer , fibrinogen , protein c and s were normal .
the embolic source of stroke in our patient remains unclear ; however , this is the first report of a ts patient with an embolic stroke pattern .
our case suggests another possible mechanism of stroke in ts that is different from previous case reports .
ischemic stroke in ts could be due to embolism as well as various cerebral arteriopathies .
further investigation is needed to more fully understand the various mechanisms of ischemic stroke in ts .
ischemic stroke in ts could be due to embolism as well as various cerebral arteriopathies , as documented in previous reports .
further studies are needed to determine the extent of the underlying mechanisms of ischemic stroke in ts .
this case report has been approved by the institutional review board of the inha university hospital .
 only a few cases of turner syndrome ( ts ) with ischemic stroke have been reported . 
 various arteriopathies of the cerebral arteries , including fibromuscular dysplasia , congenital hypoplasia , moyamoya syndrome , and premature atherosclerosis have been assumed to be the cause of ischemic stroke in ts . 
 there has been no case report of a ts patient presenting with an embolic stroke pattern without any cerebral arteriopathy . a 28-year - old woman with ts 
 was referred to our hospital because of abnormal brain magnetic resonance imaging ( mri ) findings . 
 she underwent brain mri at the referring hospital because she experienced sudden - onset diffuse headache . 
 diffusion - weighted imaging revealed multiple acute embolic infarcts in different vascular territories . 
 intracranial and extracranial arterial disease was not detected on cerebral magnetic resonance angiography and carotid sonography . 
 embolic source workups , including transthoracic and transesophageal echocardiography , holter monitoring , and transcranial doppler shunt study , were all negative . 
 hypercoagulability and vasculitis panels were also negative . 
 our patient was diagnosed with cryptogenic embolic stroke . 
 this is the first report of a ts patient with an embolic stroke pattern . 
 our case shows that ischemic stroke in ts could be due to embolism as well as the various cerebral arteriopathies documented in previous reports . 