Ischemic Stroke Revealing Previously Undiagnosed Wolff-Parkinson-White Syndrome: Suspected Role of Undocumented Paroxysmal Atrial Fibrillation

Abstract

Background: Wolff–Parkinson–White (WPW) syndrome is a cardiac conduction disorder characterized by the presence of an accessory atrioventricular pathway responsible for ventricular pre-excitation and predisposition to supraventricular tachyarrhythmias. Although frequently diagnosed in younger individuals, some patients remain asymptomatic until adulthood. The occurrence of ischemic stroke in association with WPW syndrome is uncommon and may suggest an underlying cardioembolic mechanism related to atrial fibrillation, particularly when paroxysmal and undocumented. Case Presentation: We report the case of a 58-year-old man with a history of type 2 diabetes mellitus and chronic tobacco use who presented with hemodynamic instability caused by rapid supraventricular tachycardia. Two months before admission, the patient had experienced an ischemic stroke involving the left middle cerebral artery territory without an identified etiology despite extensive evaluation. He also reported recurrent exertional palpitations and transient syncopal episodes. Emergency electrical cardioversion restored sinus rhythm. Electrocardiography subsequently revealed a short PR interval and delta waves consistent with Wolff–Parkinson–White syndrome. Transthoracic echocardiography demonstrated mildly reduced left ventricular systolic function without intracardiac thrombus. Although 24-hour rhythm monitoring failed to document atrial fibrillation, the clinical presentation strongly suggested intermittent paroxysmal atrial fibrillation as the probable mechanism of cardioembolism. Anticoagulation therapy and antiarrhythmic treatment were initiated, and catheter ablation was planned. Discussion: This case highlights the potential relationship between WPW syndrome and ischemic stroke through undocumented paroxysmal atrial fibrillation. Short-duration cardiac monitoring may fail to detect intermittent arrhythmias, particularly in patients with embolic stroke of undetermined source. Current guidelines emphasize the importance of prolonged rhythm monitoring in cryptogenic stroke patients to improve arrhythmia detection and optimize secondary prevention strategies. Conclusion: Previously undiagnosed WPW syndrome may rarely be revealed by ischemic stroke. In patients with cryptogenic stroke and suggestive symptoms such as palpitations or syncope, prolonged cardiac rhythm monitoring should be considered to identify occult atrial fibrillation and guide appropriate therapeutic management.