Retrograde cerebral embolism and pulmonary embolism caused by patent ductus arteriosus: a case report.

BACKGROUND: Although rare, paradoxical embolism sometimes occurs with patent ductus arteriosus (PDA). This study presents a case of PDA-associated paradoxical embolism with acute ischemic stroke (AIS) and pulmonary embolism (PE) following thoracoscopic surgery. CASE PRESENTATION: A 65-year-old woman developed acute-onset aphasia and right hemiparesis on the third day following thoracoscopic resection for a right lung tumor. Brain magnetic resonance imaging revealed multiple infarcts, and lower extremity venous Doppler ultrasound revealed deep vein thrombosis. The patient subsequently developed dyspnea, tachycardia, and hypoxemia. PE was confirmed by percutaneous transfemoral venous selective pulmonary angiography, which meanwhile demonstrated a PDA lesion. The patient, after receiving catheter-directed thrombolysis and inferior vena cava filter placement, improved in both neurological and respiratory status. CONCLUSION: For an uncommon but potentially fatal case with PDA-induced paradoxical embolism causing AIS and PE, early recognition and treatment are vital. Further studies are warranted to determine the optimal management and prognosis of patients with PDA-related embolic events.

[Management of patent foramen ovale in non-cardiac surgery]. / Gestione della pervietà del forame ovale nella chirurgia non cardiaca.

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Retinal arterial occlusion and patent foramen ovale: A case study-based review.

PURPOSE: To identify all reported cases of retinal artery occlusion (RAO) associated with patent foramen ovale (PFO) in the literature and present a similar case of CRAO from our clinic. METHODS: PubMed database was searched for studies reporting RAO in individuals with PFO. Relevant data were tabulated and reviewed. We estimated each case's Risk of Paradoxical Embolism (RoPE) score. RESULTS: 23 cases of CRAO (n=10; including ours), BRAO (n=10), and CILRAO (n=3) were reviewed. Most cases were under 50 years of age (78.3%). The reported predisposing factors were: hypertension (26.1%), migraine (17.3%), smoking (13.0%), recent immobilization (13.0%), strenuous exertion (8.7%), pregnancy (8.7%), and diabetes (4.3%). A high RoPE score (≥7; suggestive of paradoxical embolism via PFO) was estimated for 71.4% of patients. In most cases, the neurological and cardiovascular examinations, laboratory studies, and imaging were unremarkable, except for the PFO±atrial septal aneurysm (present in 21.7%). In only 28.6% of cases, transthoracic echocardiography (TTE) (± saline contrast) could visualize the PFO; transesophageal echocardiography (TEE) was necessary to detect the PFO in 71.4%. Approximately one-half of the patients underwent percutaneous closure of the PFO; no complications or subsequent acute ischemic events ensued. The visual prognosis was poorer for CRAO than for BRAO or CILRAO. CONCLUSION: Timely diagnosis, acute management, and ensuring urgent initiation of stroke workup in cases with RAO or transient monocular vision loss are crucial. Clues to a possible paradoxical embolism as the cause include the absence of known cardiovascular risk factors, young age, migraine, recent immobility, vigorous exercise, and pregnancy.

Endovascular Intervention for May-Thurner Syndrome in a Pregnant Patient with a Patent Foramen Ovale and Paradoxical Embolism.

May-Thurner syndrome (MTS) is a known structural risk factor for deep vein thrombosis (DVT) and embolism. In patients with a patent foramen ovale (PFO), emboli originating from the deep veins are able to paradoxically reach the systemic circulation via the PFO, consequently resulting in transient ischemic attacks (TIA) or stroke.We report the case of a 31-year-old pregnant woman, with a recent history of TIA, who presented with chronic bilateral numbness, pain, and swelling in the lower extremities. On imaging, she was found to have a PFO and MTS. Her pregnancy was subsequently terminated. This decision was made independently by the patient. Her care team did not advise her to terminate her pregnancy as there was no specific medical reason to do so. However, the patient was in significant physical pain and distress and ultimately was not comfortable continuing with the pregnancy. This highlights the complex, multifactorial decision-making process that pregnant patients with comorbid health conditions undertake. The patient then underwent transcatheter PFO closure and stents were placed bilaterally in the left and right common iliac veins. Following the stent procedure, lower extremity symptoms swiftly resolved, allowing the patient to significantly improve her ability to ambulate. There have been no signs of TIA since her procedures, and her venous symptoms have been stable.In patients with TIA or stroke from a paradoxical embolism, MTS should be considered as a potential etiology. Endovascular intervention to treat the underlying MTS should also be considered to decrease the risk of recurrent DVT and embolism.

Cardiac metastasis causes paradoxical malignant embolism.

BACKGROUND: Embolic events play an important role in clinical everyday practice. Malignant arterial embolism is a rare nevertheless often fatal entity for cardiac, cerebral or systemic ischemia, requiring immediate diagnosis and treatment. CASE: This is a case report of a 65 years-old female, suffering from pulmonal adenocarcinoma, who was hospitalized due to neurological deficits caused by an acute ischemic stroke, followed by anterior myocardial infarction within 3 days. Diagnostic work-up revealed metastasis of the pulmonal adenocarcinoma in the right atrium and a patent foramen ovale. Histopathological examination of the coronary embolus verified paradoxical arterial embolism of the pulmonal adenocarcinoma into a coronary vessel and consequently cerebral arteries. CONCLUSION: The present case underlines the need for (i), consideration of malignant embolism, (ii) histopathological examination of the embolus to determine its etiology, and (iii) interdisciplinary discussion of individual therapeutic and prevention strategies in cancer patients with cerebral, cardiac or systemic embolic events.

A Rare Presentation of Multi-Organ Embolism in a Multifactorial Hypercoagulable State: Case Report.

Paradoxical embolism is an uncommon phenomenon, accounting for only 2% of all cases of systemic arterial embolism. This condition suggests the presence of a patent foramen ovale, present in 20% - 25% of the adult population. The authors report the case of a 63-year-old male patient with a history of lung adenocarcinoma and hereditary thrombophilia admitted to hospital with acute onset of dyspnea, diplopia, confusion and decreased motor strength of the right limbs. Cranial computed tomography scan showed acute ischemic injury in the left posterior cerebral artery and computed tomography pulmonary angiography revealed bilateral pulmonary thromboembolism. A transesophageal echocardiogram confirmed the presence of patent foramen ovale. The patient was treated with anticoagulant therapy with progressive clinical improvement. Due to a high risk of recurrent thromboembolic episodes, the percutaneous closure of patent foramen ovale was performed and anticoagulant therapy was maintained indefinitely.

A embolização paradoxal é um fenómeno incomum, correspondendo apenas a 2% de todos os casos de embolia sistémica arterial. Esta condição sugere a presença de foramen ovale patente, presente em 20% - 25% da população adulta. Os autores relatam um caso de um homem de 63 anos, com os diagnósticos prévios de adenocarcinoma do pulmão e trombofilia hereditária, admitido no hospital com quadro agudo de dispneia, diplopia, confusão e diminuição da força dos membros à direita. A tomografia computorizada crânio-encefálica mostrou uma lesão isquémica cerebral na região da artéria cerebral posterior esquerda e a angiotomografia computorizada torácica revelou tromboembolismo pulmonar bilateral. O ecocardiograma transesofágico confirmou a presença de foramen ovale patente. O doente foi tratado com terapêutica anticoagulante com melhoria clínica progressiva. Devido ao elevado risco de recorrência de eventos tromboembólicos, o doente foi submetido a encerramento percutâneo do foramen ovale patente e a anticoagulação foi mantida por tempo indeterminado.

[Impending Paradoxical Embolization in a Patient with a Thrombus Straddling the Patent Foramen Ovale].

The patent foramen ovale (PFO) is known as a risk of paradoxical embolism in patients with deep venous thromboses. However, PFO is usually found after systemic embolic symptoms become apparent. A 60-year-old male had complained of dyspnea for two weeks. Ultrasound echocardiography showed a thrombus straddling PFO, and venous echography showed blood clots in the right popliteal and soleus veins. Contrast computed tomography revealed multiple pulmonary embolisms and a thrombus in the right atrium expanding to the left atrium through the atrial septum. The straddling thrombus in the atrium and pulmonary thrombi were extirpated under circulatory arrest with deep hypothermia. An inferior vena cava filter was inserted intravenously four days after surgery. The patient was discharged on the 19th postoperative day without any signs of thromboembolism. Prompt surgery is considered important to prevent thromboembolism in the case of impending paradoxical embolism.

Cerebral paradoxical embolisation in a patient with cystic fibrosis with patent foramen ovale: a comparative review of literature.

A 52-year-old woman with cystic fibrosis presented to the emergency department with expressive aphasia and right-sided hemiparesis. CT scan of the brain revealed a left middle cerebral artery territory infarct. A diagnosis of cerebral paradoxical embolisation associated with patent foramen ovale and a history of deep venous thrombosis was made. The patient underwent endovascular thrombectomy and percutaneous closure of patent foramen ovale. Current literature, including five published case reports, pertaining to the subject is discussed. The unique aspects of the case are highlighted, including the particular risk of cerebral paradoxical embolisation in patients with cystic fibrosis. The result of this case report, in context to previously reported literature, suggests that clinicians should be aware of paradoxical embolisation in patients with cystic fibrosis via an intracardiac shunt, particularly with implanted vascular access devices and a history of deep venous thrombosis.

Chronic Small Cortical Cerebellar Infarctions on MRI are Associated with Patent Foramen Ovale in Young Cryptogenic Stroke.

BACKGROUND: In acute infarction patients, small cortical cerebellar infarctions (SCCI) on MRI (assessed on diffusion-weighted imaging, with SCCI often chronic and asymptomatic) are associated with acute cardioembolic infarction. In young cryptogenic stroke patients, patent foramen ovale (PFO) is thought to be a potential source of cardioembolic infarction. We hypothesize that SCCI on MRI would be associated with PFO in young cryptogenic stroke patients. METHODS: A total of 321 consecutive young (≤50 years) stroke patients admitted between January 2015 and July 2019 were screened. Of these patients, 287 patients had diagnostic work-up including early-phase MRI, intra- and extracranial vessel imaging, contrast transoesophageal or contrast transthoracic echocardiography, and ≥24 h ECG-monitoring. We retrospectively analyzed MRI scans of the 112 patients with cryptogenic stroke, including 63 with and 49 without PFO. Between both groups, we compared baseline characteristics (including cardiovascular risk factors and history of stroke), MRI characteristics of acute symptomatic infarction (cortical/subcortical localization, arterial territory, lesion number, and lesion size in case of subcortical infarction), atrial septum aneurysm (ASA) presence, and acute and chronic SCCI and non-SCCI lesions assessed on diffusion-weighted imaging. RESULTS: Groups with and without PFO were comparable in regard to performed vessel imaging and echocardiography modalities, baseline characteristics, and acute infarction characteristics, except for more frequent current smoking (67 vs. 44%, p = 0.022) and multiterritorial infarction (14 vs. 0%, p = 0.0024) and less frequent ASA (10 vs. 48%, p < 0.001) in the group without PFO. Risk of Paradoxal Embolism score was >6 in 76% of patients with PFO. SCCI was more frequent in patients with than without PFO (33 vs. 10%, p = 0.0061; OR 4.4, 95% CI 1.5-12.7), with chronic and asymptomatic SCCI in the vast majority of cases. No difference was observed for non-SCCI lesions. CONCLUSIONS: Chronic SCCI are strongly associated with PFO in young cryptogenic stroke patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT04043559.

Acute Limb Ischemia Secondary to Patent Foramen Ovale-Mediated Paradoxical Embolism: A Case Report and Systematic Review of the Literature.

BACKGROUND: Paradoxical embolism is the translocation of a thrombus originating in the systemic venous circulation into the arterial circulation through a cardiac defect, most commonly a patent foramen ovale (PFO). PFO exists in 15-35% of the adult population. The most common manifestation is cerebrovascular accident; acute limb ischemia is much rarer. METHODS: A 67-year-old woman with multiple confounding risk factors for hypercoagulability presented with grade IIb left lower limb ischemia secondary to thromboembolism through a previously silent PFO. Management included urgent embolectomy, prophylactic fasciotomy, postoperative anticoagulation, and PFO closure. A systematic literature review of PFO-mediated acute limb ischemia was performed to identify the patient populations most commonly affected, the anatomic distribution of emboli, and patient management. RESULTS: Forty-three reports including 51 patients with first-time PFO-mediated paradoxical embolism were identified. Fifty-one percent were men, and the average age at presentation was 54 years. Multiple limbs were affected in 14 patients (27.5%), and a propensity for the lower limbs (72%) and left-sided circulation (82%) was noted. Deep venous thromboembolism was identified in 36 patients (71%). Immediate anticoagulation was instituted in 31 patients. Embolectomy and/or fibrinolysis were performed in 45 patients (88%). CONCLUSIONS: Acute limb ischemia is a rare manifestation of PFO-mediated paradoxical embolism that requires a high index of suspicion for diagnosis. Middle-aged individuals appear to be more commonly affected, and acute limb ischemia most often occurs in the lower limbs and left-sided circulation, with the potential to affect multiple extremities simultaneously. Prompt identification and surgical embolectomy with prophylactic fasciotomy can facilitate successful outcomes. Perioperative management should include anticoagulation and may include workup with echocardiography, duplex ultrasound, and hypercoagulability testing.

Emergency thromboembolectomy for impending paradoxical embolism through a patent foramen ovale owing to venous thromboembolism in a severely obese patient.

A severely obese patient with dyspnea and weighing 197 kg presented to us. He experienced an impending paradoxical embolism in the left ventricle caused by a deep vein thrombosis passing through a patent foramen ovale, as well as an acute massive pulmonary thromboembolism. Emergency thromboembolectomy from the right atrium and the bilateral pulmonary arteries was successfully performed. This is an extremely rare case of a severely obese patient with a body mass index of 66.6 kg/m2 who required emergency cardiac surgery by a cardiopulmonary bypass.

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 arterial gas embolism following a direct incisive injury to the skull]. / Embolismo arterial gaseoso paradojico tras una herida incisa craneal directa.

INTRODUCTION: An arterial gas embolism is defined as the presence of air in the arterial circulation. This is an extremely rare cause of stroke that has been described in a multitude of clinical scenarios, generally related to iatrogenic processes. A clinical case is reported in which the arterial gas embolism occurred after a traumatic brain injury, and the most relevant aspects of diagnosis and aetiopathogenesis are reviewed. CASE REPORT: We report the case of a 52-year-old woman with an open craniofacial wound resulting from an attack with an axe. The initial CT scan found fractures in the left zygomatic, sphenoidal and maxillary arches, as well as pneumocephalus in the cavernous sinuses and the right carotid canal. One hour later, the patient showed a neurological deficit in the right hemisphere, and so a new cranial computed tomography scan with multimodal vascular study was urgently requested, which revealed the mobilisation of the pneumocephalus and ruled out a large vessel arterial occlusion. A shunt study using transcranial Doppler and echocardiography showed the presence of a patent foramen ovale to be the cause of arteriovenous communication that justified an arterial gas embolism. The follow-up CT scan at 48 hours confirmed the appearance of a right parietal ischaemic lesion. CONCLUSION: This case reflects the simultaneous presence of air in the arterial and venous circulation of the brain, as well as the peripheral communication through a patent foramen ovale. This production mechanism is poorly documented in the literature.

TITLE: Embolismo arterial gaseoso paradojico tras una herida incisa craneal directa.Introduccion. El embolismo arterial gaseoso se define como la presencia de aire en la circulacion arterial. Se trata de una causa extremadamente rara de ictus que se ha descrito en multitud de escenarios clinicos, generalmente relacionados con procesos yatrogenos. Se aporta un caso clinico en el que el embolismo arterial gaseoso sucedio tras un traumatismo craneoencefalico, y se revisan los aspectos mas relevantes del diagnostico y la etiopatogenia. Caso clinico. Mujer de 52 años que presentaba herida incisa craneofacial tras una agresion con un hacha. La tomografia computarizada inicial objetivo fractura en los arcos cigomatico, esfenoidal y maxilar izquierdos, asi como neumoencefalo en los senos cavernosos y el canal carotideo derecho. Una hora mas tarde, la paciente mostro un deficit neurologico hemisferico derecho, por lo que se solicito de forma urgente una nueva tomografia computarizada craneal con estudio vascular multimodal, que objetivo la movilizacion del neumoencefalo y descarto una oclusion arterial de gran vaso. Un estudio de shunt mediante Doppler transcraneal y ecocardiografia comprobo la presencia de un foramen oval permeable como causa de comunicacion arteriovenosa que justificaba un embolismo arterial gaseoso. La tomografia computarizada de control a las 48 horas confirmo la aparicion de una lesion isquemica parietal derecha. Conclusion. En este caso queda reflejada la presencia simultanea de aire en la circulacion cerebral arterial y venosa y la comunicacion periferica a traves de un foramen oval permeable. Este mecanismo de produccion esta escasamente documentado en la bibliografia.

Impending Paradoxical Embolism.

Impending paradoxical embolism (IPDE) is the presence of a thrombus in the patent foramen ovale. Usually, IPDE is diagnosed by echocardiography or a multislice computed tomography scan and is performed during the evaluation of a patient presenting with suspected pulmonary embolism. We report 2 patients who presented with IPDE and were successfully treated with cardiac surgery and thrombolytic therapy. Thus, we focus our discussion on the diagnosis and treatment modalities of this rare entity.

Patent foramen ovale and long-term risk of ischaemic stroke after surgery.

AIMS: Pre-operatively diagnosed patent foramen ovale (PFO) is associated with an increased risk of ischaemic stroke within 30 days after surgery. This study aimed to assess the PFO-attributable ischaemic stroke risk beyond the perioperative period. METHODS AND RESULTS: This observational study of adult patients without history of stroke undergoing non-cardiac surgery with general anaesthesia examined the association of PFO with ischaemic stroke 1 and 2 years after surgery using multivariable logistic regression. Of the 144 563 patients included, a total of 1642 (1.1%) and 2376 (1.6%) ischaemic strokes occurred within 1 and 2 years after surgery, 54 (4.7%) and 76 (6.6%) among patients with PFO, and 1588 (1.1%) and 2300 (1.6%) among patients without PFO, respectively. The odds of ischaemic stroke within 1 and 2 years after surgery were increased in patients with PFO: adjusted odds ratio (aOR) 2.01, 95% confidence interval (CI) 1.51-2.69; P < 0.001 and aOR 2.10, 95% CI 1.64-2.68; P < 0.001, respectively. Among patients who underwent contrast transoesophageal echocardiography, the frequency of PFO was 27%, and the increased stroke risk in patients with PFO was robust (aOR 3.80, 95% CI 1.76-8.23; P = 0.001 for year 1). The PFO-attributable risk was mitigated by post-operative prescription of combination antithrombotic therapy (odds ratio 0.41, 95% CI 0.22-0.75; P for interaction = 0.004). CONCLUSION: Patients with PFO are vulnerable to ischaemic stroke for an extended period of time after surgery. Physicians should consider implementing PFO screening protocols in patients scheduled for major non-cardiac surgery.

Paradoxical embolism with thrombus stuck in a patent foramen ovale: a review of treatment strategies.

OBJECTIVE: Paradoxical embolism represents a rare condition occurring when a thrombus originating from venous system produces pulmonary embolism and systemic embolization through an intracardiac or pulmonary shunt. The evidence of a thrombus entrapped in a patent foramen ovale (PFO) is an even more rare condition. There is uncertainty about the optimal treatment strategy. PATIENTS AND METHODS: A 58-year-old male patient was admitted to our Internal Medicine Unit with the diagnosis of bilateral bronchopneumonia. During hospitalization, the co-occurrence of chest pain and amaurosis led us to hypothesize a paradoxical embolism. RESULTS: Transthoracic echocardiography showed the presence of a thrombus stuck over the interatrial septum. A contrast-enhanced chest CT scan showed multiple pulmonary embolisms and brain CT scan documented a hypodense area, of ischemic significance, in the left occipital lobe near tentorium. In order to prevent further embolization, emergency cardiac surgery (right atriotomy, removal of thrombus and closure of the PFO, pulmonary thrombectomy) was performed without complications. CONCLUSIONS: Although rare, the evidence of a thrombus stuck in a patent foramen ovale represents a clinical emergency. The optimal therapeutic approach is still debated. The surgical correction seems to be a safe and effective option for these patients.

Trombo a través de foramen oval permeable: embolia paradojal cerebral y factores de alto riesgo de recurrencia. Caso clínico / Paradoxical embolism due to a persistent patent foramen ovale: report of one case

Abstract: Patent Foramen Ovale (PFO) is one of the most frequent congenital defects in adults. Its prevalence in middle-aged adults is close to 25-30% and may cause paradoxical embolic phenomena. We report a 45 years old male admitted for an ischemic stroke with an occlusion of the left terminal internal carotid artery. A thrombectomy was performed. Searching for possible sources of emboli, a patent foramen ovale was detected in an echocardiography, with an hypoechogenic examination image passing through it. Anticoagulant therapy was started and the patient had an uneventful evolution.

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.