Closing a hole in her heart stopped the symptoms in her brain

In September 2022, Susan Scalzi was eating dinner with her husband when he asked if she felt okay.

"Actually, I don't," she told him. The 47-year-old had a headache and felt dizzy and unstable. He drove her to the closest emergency room, minutes from their home in Chester County, Pa. By the time they arrived, Susan had paralysis on the right side of her body and difficulty speaking.

The emergency team did an MRI of her brain, but the test showed no sign of a stroke. A neurologist at the hospital told Susan she was experiencing a hemiplegic migraine, which can mimic a stroke. She was admitted to the hospital for several days of therapy and regained strength on her right side.

"I didn't have a history of migraine, so that was a little strange. My father had strokes in the past, which we believed were related to diabetes, which I don't have. So I didn't think of myself as being at risk," Susan says.

After her discharge, she was referred to a neurologist who prescribed a migraine medication, and life returned to normal. Until her next frightening incident.

Escalating stroke symptoms and a surprising suggestion

It was early January and Susan was on the couch with her daughter, who was home from college on winter break.

"We were having a normal conversation. Then, all of a sudden, I heard her yell to my husband in the other room," Susan says.

Susan's speech was garbled and she was drooling.

"Neither of them could understand me, but in my head I sounded perfectly clear," Susan says.

Her husband called 911 and Susan was taken to the emergency room. Again, her medical workup showed no sign of a stroke. This time, she was diagnosed with a transient ischemic attack (TIA), or mini-stroke. A TIA is a stroke where the symptoms go away and the brain appears normal. Regular strokes often follow.

Susan later returned to her neurologist, who said to continue with the migraine medication, then made a surprising suggestion.

"My neurologist said, 'Because you've had a history of blood clots, I also want you to see a cardiologist,'" Susan says.

Blood clots' impact on the heart

Susan had previously been diagnosed with a blood clot, likely caused by genetics or a medication she'd been taking at the time. She was given a drug to break up the clot and began taking baby aspirin as a daily preventive.

Her neurologist suspected Susan's recent issues may have been caused by a patent foramen ovale, or PFO — a hole in her heart that was allowing microemboli (tiny blood clots) to pass from her heart to her brain.

That spring, Susan's search for answers led her to Matthew Goldstein, MD, a cardiac electrophysiologist at Paoli Hospital, part of Main Line Health.

Prior to seeing him, Susan had an echocardiogram that revealed a PFO. Dr. Goldstein explains that when a baby is in the womb, "there's a built-in hole in the heart where blood crosses from the right atrium (upper chamber) to the left, skipping the lungs. For the majority of people, that hole closes shortly after birth."

Normally, blood flows from the right chambers of the heart to the lungs, where blood cells shed carbon dioxide and fill with oxygen. The lungs filter out any small clots before the blood continues to the left chambers of the heart, which pumps the oxygen-rich blood to the rest of the body before it circulates back to the right chambers.

"With a PFO, sometimes little pieces of blood clots cross over that hole in the heart and go to the brain, which can cause a variety of issues," Dr. Goldstein says. These issues include seizures, strokes, mini-strokes and migraines.

To better understand what was happening, Dr. Goldstein ordered a transesophageal echocardiogram (TEE). Susan was given an intravenous saline solution containing tiny bubbles to visually track her blood flow. If the bubbles traveled directly from the right atrium to the left, or if non-bubbly blood crossed from the left to the right, it would indicate a PFO — which is what happened.

Dr. Goldstein also used a loop recorder, a microchip implanted under Susan's skin, to check for heart rhythm issues. "When that test came back normal, we knew that the likely cause was this structural problem of the heart she was born with that was now causing problems," Dr. Goldstein says.

Closing the PFO without surgery

In August 2023, Dr. Goldstein performed a PFO closure in the electrophysiology lab at Paoli Hospital. Guided by ultrasound imaging, Dr. Goldstein inserted a catheter (thin tube) through Susan's groin into her heart, along with a closure device. The device is like two umbrellas opened on either side of the hole and pressed together to form a seal. Dr. Goldstein tested the seal by injecting tiny bubbles at the site.

The procedure took less than an hour and Susan went home the same day.

Many people unknowingly live with a PFO. "It's not something we generally recommend screening for unless you've had a clinical event that can't be explained," Dr. Goldstein says. "And if you have an echocardiogram that shows a PFO but you've never had a stroke, migraine, or other issue, we don't recommend fixing it."

Achieving a full recovery

Susan's procedure went smoothly, and because it was summer, she had ample time to recover before resuming her job teaching medical coding at a community college.

Since her PFO closure, Susan hasn't had any symptom recurrence and hopes sharing her experience will help others.

It has also helped her. "This was the push I needed to lose weight, eat healthier, exercise more and make some lifestyle changes to improve my quality of life," she says.

While Susan has always been proactive about seeking care, she has a greater awareness now of how important it is to know your family medical history and share that with your doctor. She also recognizes that heart issues can show up in unexpected ways.

As Dr. Goldstein says, "Most people think a brain issue is a brain issue. They don't think it could be caused by the heart."

Next steps:

Make an appointment with Matthew Goldstein, MD
Learn more about Paoli Hospital's new interventional labs 
Can you have a stroke at a young age?