Multiple Intracardiac and Paradoxical Thrombi Caused by a Thrombus Entrapped in a Patent Foramen Ovale.

Patent foramen ovale (PFO) usually represents a benign incidental finding. Occasionally, a PFO can open widely, resulting in paradoxical embolism, with potentially devastating consequence. Floating intracardiac thrombi and thrombus straddling a PFO are 2 extremely rare conditions associated with a dismal prognosis and encountered almost exclusively in the setting of pulmonary embolism (PE). We report the unusual case of a 47-year-old man with an unremarkable medical history who presented with a bilateral PE and multiple paradoxical and intracardiac floating thrombi in the setting of a thrombus entrapped in a PFO.

Acute limb ischemia due to paradoxical embolism treated with systemic thrombolysis.

We present a case report of a patient with acute upper and lower limb ischemia due to paradoxical embolism. A 67-year old woman without history of venous thromboembolism suffered dislocated patellar fracture requiring surgery in November 2017. Two months after surgery she presented to the emergency room with bilateral pulmonary embolism, occlusion of the left subclavian artery, left common femoral artery and superior mesenteric artery. Transesophageal echocardiography detected patent foramen ovale. Vascular surgeon decided against embolectomy, interventional radiologist against pharmacomechanical thrombolysis due to the extent of the occlusions. Systemic thrombolysis (alteplase) was administered successfully with resolution of the emboli in the left subclavian artery, left common femoral artery and superior mesenteric artery.

[Thrombotic complication of severe COVID-19 pneumonia: stroke due to atypical paradoxical embolism]. / Complicación trombótica de neumonía grave por COVID-19: ictus por embolismo paradójico atípico.

INTRODUCTION: Severe infection by SARS-CoV-2 has shown to entail an increased risk of thrombotic, especially venous, events. Central venous catheters have also been associated with an increased risk of thrombotic complications. Paradoxical embolism as an aetiological mechanism of ischaemic stroke should be considered in a highly prothrombotic context, where it may be more frequent. CASE REPORT: A 40-year-old woman with a central venous catheter, with a large vessel ischaemic stroke, treated with mechanical thrombectomy for an atypical paradoxical embolism while in intensive care for bilateral COVID-19 pneumonia. In the aetiological study, analysis highlighted an elevation of the D-dimer and right-left shunt with massive passage of contrast directly from the central peripheral access pathway in the left upper extremity to the left atrium in the transoesophageal echocardiogram. Thoracic tomographic angiography showed an anomalous venous structure with its origin in the subclavian vein and drainage to the segmental vein of the left upper lobe with direct emptying into the left atrium. Treatment consisted in anticoagulation until removal of the central venous catheter and simple anti-aggregating medication on discharge. CONCLUSIONS: Paradoxical embolism due to intra- or extra-cardiac shunt should be considered in patients with COVID-19, given the high associated risk of venous thromboembolism. Further studies are needed to be able to define optimal prophylactic and therapeutic management.

TITLE: Complicación trombótica de neumonía grave por COVID-19: ictus por embolismo paradójico atípico.Introducción. La infección grave por el SARS-CoV-2 ha demostrado un incremento del riesgo de fenómenos trombóticos, especialmente venosos. Los catéteres venosos centrales también se han asociado a un mayor riesgo de complicaciones trombóticas. El embolismo paradójico como mecanismo etiológico del ictus isquémico debe tenerse en cuenta en un contexto protrombótico elevado, en el que puede ser más frecuente. Caso clínico. Mujer de 40 años, portadora de un catéter venoso central, con ictus isquémico de gran vaso, tratada con trombectomía mecánica por embolismo paradójico atípico durante el ingreso en cuidados intensivos por neumonía bilateral por COVID-19. Dentro del estudio etiológico, destacaba analíticamente una elevación del dímero D y shunt derecha-izquierda con paso masivo de contraste directamente desde la vía central de acceso periférico en la extremidad superior izquierda a la aurícula izquierda en el ecocardiograma transesofágico. Una angiotomografía torácica mostró una estructura venosa anómala con origen en la vena subclavia y drenaje a la vena segmentaria del lóbulo superior izquierdo con vaciado directo a la aurícula izquierda. Se decidió anticoagulación hasta la retirada del catéter venoso central y antiagregación simple al alta. Conclusiones. El embolismo paradójico por shunt intra o extracardíaco debe considerarse en pacientes con COVID-19, dado el elevado riesgo tromboembólico venoso asociado. Para definir el manejo profiláctico y terapéutico óptimo son necesarios más estudios.

Intrahepatic Cholangiocarcinoma Associated Paradoxical Peripheral Embolism and a Submassive Pulmonary Embolism.

Paradoxical peripheral embolism and submassive pulmonary embolism (PE), secondary to cancer-associated thrombosis, are yet to be reported in the literature. Here we describe a case presenting with an acute peripheral arterial embolism. Subsequent testing revealed a PE and an intrahepatic cholangiocarcinoma as the likely risk factors for thrombus, with arterial spread likely achieved through a patent foramen ovale. The patient's symptoms almost relieved upon catheter-directed thrombus fragmentation and aspiration, catheter-directed thrombolysis, and combined anticoagulation. Embolism and major bleeding did not occur during 6 months of follow-up under systemic anticoagulation with rivaroxaban. This case documents that catheter-directed thrombolysis and anticoagulation could be likely effective and safe in the treatment and prevention of recurrence of paradoxical embolism and PE secondary to cancer-associated thrombosis.

Paradoxical Brain Embolism Caused by Isolated Pulmonary Arteriovenous Fistula Successfully Treated with Recombinant Tissue Plasminogen Activator.

Pulmonary arteriovenous fistula (PAVF), a vessel malformation connecting the pulmonary circulation to the systemic circulation while bypassing the pulmonary capillaries, can cause paradoxical cerebral infarction. It is often associated with hereditary hemorrhagic telangiectasia (HHT), a genetic disease characterized by multiple dermal, mucosal, and visceral telangiectasia causing recurrent bleeding. Paradoxical cerebral embolism caused by PAVF without HHT is rare. Here, we report a patient with isolated PAVF who experienced an ischemic stroke caused by a paradoxical embolism from deep venous thrombosis; the patient was successfully treated with recombinant tissue plasminogen activator. She presented with a decrease in arterial oxygen saturation to 91%, and lung disease was suspected. A PAVF was subsequently found in the right S6 region using contrast computed tomography. Interventional radiologists successfully occluded the shunt using 6 microcoils. PAVF should be considered when determining the pathogenesis of cerebral ischemia in patients with hypoxia, which can be the only symptom of PAVF.

Frequent Arterial Emboli in a Patient with Acute Pulmonary Thromboembolism and Patent Foramen Ovale.

Although patent foramen ovale (PFO) is a relatively common condition, the risk of paradoxical embolism is less than 2% of all arterial ischemia. We present the case of a 52-year-old man diagnosed with pulmonary thromboembolism complicated with 2 events of paradoxical emboli in the left upper and right lower limbs secondary to PFO. We also discuss some uncertainties behind the management of PFO patients after an episode of venous thromboembolism.

Pulmonary embolism and infarction with a paradoxical thrombus visualised in both atria.

A 59-year-old woman presented with a sudden onset of breathlessness and chest pain. An echocardiography and CT scan showed pulmonary embolism and infarction with a paradoxical thrombus visualised in both atria. For haemodynamically stable patients, the optimal management strategy is poorly defined. Three main strategies were considered: surgical thrombectomy, thrombolysis and anticoagulation. Surgery with reversal of anticoagulation may lead to further coagulation and increased risk of bleeding complications. The significant pulmonary hypertension and right ventricular infarction raised the prospect of difficult weaning from cardiopulmonary bypass following thrombectomy. Thrombolysis, which has significant mortality rate, and systemic embolisation including pulmonary infarction with haemorrhagic transformation were also contraindications. A multidisciplinary approach was adopted and anticoagulation was therefore believed to be the safest and effective approach. Here, the use of anticoagulation alone was fortunately successful but could as easily end in disaster. This approach should be considered the ideal paradigm to yield optimum outcomes.

Paradoxical Cerebral Embolism after Gastrointestinal Endoscopy in a Patient with Crohn's Disease.

Development of paradoxical cerebral embolism requires both unstable venous thrombosis and right-to-left shunt (RLS). Gastrointestinal endoscopy (GE) has the potential to affect intrathoracic and abdominal venous thrombi and to enhance RLS because the procedure alters intrathoracic and abdominal pressure. We describe a patient with Crohn's disease who developed paradoxical cerebral embolism after GE. Both an unstable venous thrombus in the superior vena cava and RLS through patent foramen ovale were thought to be responsible for the stroke. Considering that patients with digestive system diseases undergo GE as a routine examination or therapy, screenings for hypercoagulable state and intrathoracic and abdominal thrombi are important to prevent thromboembolism related to GE.

Tissue Plasminogen Activator to Treat a Stroke after Foam Sclerotherapy in a Woman with a Patent Foramen Ovale.

Although foam sclerotherapy to varicose veins is now a popular treatment because of its high efficacy and safety, some neurologic complications have recently been reported. Presently, the effectiveness and safety of intravenous recombinant tissue-type plasminogen activator therapy to stroke following foam sclerotherapy remain unclear. Here, we report the case of a 68-year-old woman whose ischemic symptoms following foam sclerotherapy were treated by intravenous recombinant tissue-type plasminogen activator. After she was admitted, the venous thrombosis in her right soleus vein and a patent foramen ovale causing the right-to-left shunt were revealed. Thus, we diagnosed the ischemic symptoms were due to paradoxical embolism following foam sclerotherapy. After intravenous recombinant tissue-type plasminogen activator therapy, there was no complication and the outcome was good. Our case suggests the effectiveness and the safety of intravenous recombinant tissue-type plasminogen activator therapy to paradoxical embolism following foam sclerotherapy.

Multiple Cerebral Infarctions Due to Patent Foramen Ovale in a Patient with Eosinophilic Granulomatosis with Polyangiitis.

A 51-year-old man was diagnosed with eosinophilic granulomatosis with polyangiitis 6 years ago due to asthma, sinusitis, hypereosinophilia, and peripheral neuropathy based on the diagnostic criteria of American College of Rheumatology, and corticosteroid therapy achieved a remission. One year ago, he was hospitalized due to deep venous thrombosis (DVT) and pulmonary embolism, and rivaroxaban was administrated. He was admitted to our hospital for acute onset of diplopia and right hemiparesis. Peripheral blood examinations disclosed leukocytosis with hypereosinophilia. Perinuclear anti-neutrophil cytoplasmic antibodies were positive. Diffusion-weighted imaging showed multiple fresh ischemic lesions. Chronic ischemic lesions were seen in subcortical cerebral region. No stenosis or occlusion was shown in extracranial and intracranial arteries on magnetic resonance angiography. Ultrasonography of leg vein showed DVT. Right-to-left shunt through patent foramen ovale after Valsalva maneuver was seen on transesophageal echocardiography. Treatment with corticosteroid and cyclophosphamide alleviated clinical deterioration. Rivaroxaban was changed to warfarin. Diplopia and muscle strength of right limbs were improved. This is a first case of multiple cerebral infarction caused by paradoxical embolism due to patent foramen ovale with DVT based on hypercoagulable state of hypereosinophilia. Overall this case illustrates that eosinophilic granulomatosis with polyangiitis can be a risk factor for multiple cerebral infarction in the systemic phase and that transesophageal echocardiography and ultrasonography of leg vein should be conducted in stroke patient with eosinophilic granulomatosis with polyangiitis.

Paradoxical Embolism in a Girl with Atrial Septal Defect After Paroxysmal Supraventricular Tachycardia Ablation.

Paradoxical embolism is a kind of important pathogenesis of cardiocerebrovascular diseases. In our case, radiofrequency current catheter ablation was accomplished successfully in a 15-year-old girl who had been experiencing supraventricular tachycardia for 6 months. She presented with abrupt onset of left hemiplegia and loss of consciousness on the first postoperative day. An urgent cerebral computed tomography showed a hyperdense right middle cerebral artery. Transthoracic echocardiogram examination revealed an atrial septal defect (ASD), with the diameter measuring 39 mm. The case highly suggests that the issue of ASD should be resolved by either closed or prompt anticoagulant therapy, especially for patients who are planned to receive catheter manipulation.

Paradoxical embolism: A report of 2 cases.

RATIONALE: Paradoxical embolism (PDE) refers to direct passage of venous thrombi into the arterial circulation through an arteriovenous shunt. PATIENT CONCERNS: Case 1 presented with initial symptoms of shock and cerebral infarction. Case 2 developed middle cerebral artery occlusion during angiography. DIAGNOSES: 2 cases were diagnosed as PDE. INTERVENTIONS: They received thrombolytic therapy and anticoagulant therapy. OUTCOMES: The patients had recovery. LESSONS: This report highlights the myriad clinical manifestations of PDE and underlines the importance of meticulous history taking and physical examination for early diagnosis.

Concomitant coronary and pulmonary embolism associated with patent foramen ovale: A case report.

RATIONALE: The differential diagnosis of acute chest pain is very important, and can sometimes be challenging. Related diseases share a number of risk factors, and occasionally, 1 condition causes another disease to develop. PATIENT CONCERNS: We described a 59-year-old man who presented to emergency department complaining of chest pain. DIAGNOSES: He was suffered acute myocardial infarction (MI) and pulmonary embolism (PE) simultaneously. INTERVENTIONS: Dual antiplatelet therapy, statin, and low molecular weight heparin were administrated during his stay. The searches for cancers, autoimmune diseases, and hematologic diseases were unremarkable, ruling out a hypercoagulable state. Subsequent ultrasound scan revealed a thrombus in a vein of the lower left extremity. Thus, paradoxical embolism was highly suspected. OUTCOMES: Paradoxical embolism is a rare cause of acute MI, which may have occurred in our patient. This was evidenced by a previously unrecognized patent foramen ovale (PFO) with a right-to-left atrial shunt detected using contrast transesophageal echocardiography. LESSONS: Acute MI complicated with PE is not common in the clinical setting. The fatal condition is difficult to diagnose because of the similar symptoms and confusing causes. Paradoxical embolism can cause this phenomenon, and physicians should be highly vigilant in the search for a PFO in cases of paradoxical embolism.

An Unusual Cause of Cardioembolic Stroke: Paradoxical Embolism Due to Thrombus Formation on the Eustachian Valve.

Cardioembolism is an important cause of ischemic stroke, with several studies showing worse outcome than following other stroke subtypes. Paradoxical embolism is a rare cause of cardioembolic stroke. We report a case of a patient with presumed paradoxical cardioembolic stroke secondary to thrombus formation on the eustachian valve remnant in the right atrium. The patient was anticoagulated with resolution of the mass upon follow-up assessment. The diagnostic, investigative and management strategies are discussed for patients with suspected paradoxical embolism causing stroke. Physicians are reminded of the utility of echocardiography for identifying potential cardioembolic etiologies, including both transthoracic and transesophageal echocardiography.

Clinical outcomes after intravenous fibrinolysis in cryptogenic strokes with or without patent foramen ovale.

BACKGROUND: Pivotal clinical trials suggest that intravenous (IV) recombinant tissue plasminogen activator (rt-PA) benefits stroke patients regardless of the underlying etiology. Paradoxical strokes, presumed to be caused by fibrin-rich clots originating in the venous circulation, may respond better to fibrinolysis than other ischemic stroke subtypes. In this study, we compared the response with IV rt-PA in paradoxical stroke patients and other stroke subtypes. METHODS: In total, 486 patients treated with IV rt-PA at a single institution were retrospectively reviewed. Adjudication of stroke mechanism was based on chart review. Five major stroke mechanisms--cardioembolic, artery-to-artery emboli, lacunar, cryptogenic, and paradoxical--were identified by final diagnosis from chart reviews. Mimics, undefined etiology, and defined etiology not falling into the major mechanisms were excluded. Analysis of variance and general linear model were used to assess the differences between groups. RESULTS: A total of 323 patients were analyzed. We found significant differences in clinical outcome between stroke mechanisms, including discharge National Institutes of Health Stroke Scale (NIHSS) (P=.007), discharge Rankin (P=.011), discharge disposition (P=.000), and infarct volume (P=.007). Post hoc analysis showed that cardioembolic patients had the worst outcomes (discharge NIHSS score 11.12±12.26), whereas paradoxical strokes had the best outcomes (discharge NIHSS score 3.67±4.90), but these did not approach statistical significance. However, regression analysis showed that 4 variables--congestive heart failure, admission NIHSS, age, and mean infarct volume--rather than stroke mechanism were the true predictors of poor outcome. CONCLUSIONS: Paradoxical strokes had better outcomes after IV fibrinolysis than other ischemic stroke subtypes, but this difference is attributable to younger age and milder stroke severity on presentation.