Isquemia intestinal, una manifestación inusual de la embolia paradójica. Un reporte de caso / Intestinal ischaemia as a rare manifestation of a paradoxical embolism. A case report

Introducción. La embolia paradójica es un evento trombótico originado en la circulación venosa, que se manifiesta como embolismo arterial por medio de un defecto anatómico a nivel cardíaco o pulmonar. Se asocia principalmente a eventos cerebrovasculares, aunque se han encontrado casos de infarto agudo de miocardio, infarto renal y otros eventos isquémicos. Caso clínico. Paciente de 47 años, quien consultó por cuadro de dolor abdominal, que requirió manejo quirúrgico de urgencia, donde identificaron isquemia intestinal importante. Los estudios adicionales hallaron déficit de proteína S y persistencia de foramen oval permeable. Resultados. La presencia de trombosis arterial se conoce como trombosis de sitios inusuales y requiere de estudios para descartar trombofilias asociadas u otros estados protrombóticos. El déficit de proteína S es una trombofilia infrecuente, la cual se asocia en la vida adulta a eventos trombóticos de origen venoso. En presencia de defectos anatómicos, como un foramen oval permeable, puede progresar a embolia arterial, configurando un cuadro de embolismo paradójico. La estratificación de estos pacientes requiere imágenes que demuestran el defecto mencionado, así como el posible origen de los émbolos. El manejo se basa en anticoagulación plena, manejo de soporte, resolver las manifestaciones trombóticas existentes y un cierre temprano del defecto anatómico. Conclusiones. El embolismo paradójico debe sospecharse en caso de trombosis de sitios inusuales. Requiere de un estudio exhaustivo con imágenes y su manejo debe basarse en anticoagulación y cierre del defecto.

Introduction. Paradoxical embolism is a thrombotic event originating in the venous circulation, which manifests as arterial embolism through an anatomical cardiac or pulmonary defect. It is mainly associated with stroke, also presenting as acute myocardial infarction, renal infarction, and other ischemic events. Clinical case. A 47-year-old patient was admitted due to abdominal pain, which required emergency surgical management, finding significant intestinal ischemia. Additional studies found protein S deficiency and evidence of a patent foramen ovale. Discussion. Arterial thrombosis is known as unusual thrombosis; this situation requires to rule out associated thrombophilia or other prothrombotic diseases. Protein S deficiency is a rare thrombophilia, which in adults causes venous thrombosis. In the presence of anatomical defects, such as a patent foramen ovale, it can progress to arterial embolism, presenting a picture of paradoxical embolism. The study work of these patients requires imaging that demonstrates the aforementioned defect, as well as the possible origin of the emboli. Management is based on full anticoagulation, treatment of existing thrombotic manifestations, and management of the anatomical defect. Conclusions. Paradoxical embolism should be suspected in case of unusual thrombosis. It requires exhaustive studies based on imaging, and management should consist of anticoagulation and closure of the defect.

Cardiogenic shock due to pulmonary thromboembolism: the role of surgical thrombectomy / Shock cardiogénico debido a tromboembolismo pulmonar: el papel de trombectomía quirúrgica

Abstract A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Resumen Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

Analysis of 5 ischemic stroke patients caused by pulmonary arteriovenous fistula / 中华神经科杂志

Objective:To investigate the correlation between pulmonary arteriovenous fistula (PAVF) and ischemic stroke, and to improve the diagnosis and treatment of embolic strokes of undetermined source.Methods:Five patients with ischemic stroke caused by PAVF admitted to Xiangya Hospital of Central South University from January 2017 to December 2020 were collected. The diagnosis, treatment and prognosis of stroke caused by PAVF were summarized based on literature review.Results:Among the 5 patients, 1 is male and 4 are females, with age of (34.4±9.3) years. Weakness of unilateral limb, slurred speech, vision changes, drooping eyelids, etc., were the first manifestations of stroke. The location of cerebral infarction was indefinite. In this study, 5 patients were all isolated PAVF, including 3 cases of left lower lung, 1 case of left upper lung and 1 case of right lower lung. All 5 patients underwent interventional therapy, were followed-up for 6 months and 12 months after surgery, and none of them had a new stroke attack, and only 1 case had recanalization of PAVF.Conclusions:PAVF is a rare vascular lesion, stroke caused by which is even rarer, with a lack of specificity in clinical manifestations. For young patients with unexplained embolic stroke, if the stroke has a sudden onset, the anterior and posterior circulation can be involved, and multiple vascular distribution regions are often involved, and it is difficult to find a clear emboli basis, with manifestations such as hypoxemia, PAVF should be considered. Percutaneous catheter intervention for PAVF is safe and effective, and is the preferred method for the treatment of PAVF.

Acute myocardial infarction in a young patient by coronary embolism / Infarto agudo de miocardio en un paciente joven causado por embolia coronaria

Abstract: Coronary artery disease continues to be the leading cause of death in modern society; the most frequent cause is atherosclerosis. There are other causes such as coronary embolism and coronary dissection, among others. This article presents the case of a young patient with acute myocardial infarction in whom a coronary embolism was documented as the cause of infarction.

Resumen: La enfermedad arterial coronaria continúa siendo una causa de mortalidad en nuestro medio; la causa más frecuente es la aterosclerosis. Existen otras causas como embolia coronaria, disección coronaria. En este artículo se describe el caso de un paciente joven, quien presentó un infarto agudo de miocardio y se documentó un embolia conoraria como causa.

Tromboembolia pulmonar e infarto de miocardio embólico en paciente con trombo en tránsito a través de foramen oval permeable / Pulmonary embolism and embolic myocardial infarction in a patient with thrombi in transit through a patent foramen ovale

Resumen Se presenta el caso de una paciente ingresada por cuadro clínico de infarto agudo de miocardio con elevación del segmento ST. Tras la realización de una coronariografía emergente en la que se evidencia un trombo en la arteria coronaria derecha, sin objetivar lesiones ateroscleróticas, es diagnosticada de infarto de probable origen embólico. Tras realizar un ecocardiograma transtorácico, se detecta la presencia de trombos en las cavidades derechas e izquierdas del corazón. Por ello se realiza angiografía por tomografía computarizada con protocolo de embolia pulmonar, que confirma la presencia de embolia pulmonar bilateral masiva. Tras esto, se repitió el ecocardiograma transtorácico, hallándose un aneurisma del septo interauricular, con aparente protrusión de una masa trombótica a través de él. Se inició terapia anticoagulante con buena evolución por parte de la paciente, habiendo desaparecido los trombos en el ecocardiograma con test de burbujas que se realizó días después, en el que se demostró la presencia de un foramen oval permeable. Con la presentación de este caso se pretende, en primer lugar, ilustrar una afección que en contadas ocasiones se puede objetivar mediante prueba de imagen, y en segundo lugar, hacer una breve revisión del diagnóstico y el manejo del foramen oval permeable como parte del estudio de fuente embólica.

Abstract The authors describe a case of a patient admitted with ST elevation myocardial infarction. An emergent coronariography was done, showing a thrombus in the right coronary artery, without evidence of atherosclerotic lesions in the coronary bed. Due to this, she is diagnosed with probable embolic myocardial infarction. When she was performed a transthoracic echocardiography, the presence of free thrombi was detected in right and left chambers of the heart. Due to this, a CT angiography with pulmonary embolism protocol was done, confirming the presence of a massive bilateral pulmonary embolism. After that, a new trans-thoracic echocardiography was done, finding an aneurism at interatrial septum, with an apparent protrusion of thrombotic mass through it. The decision taken was initiating therapeutic anticoagulation, having the patient a positive evolution with disappearance of thrombi in the bubble test performed days later, and showing the presence of a patent foramen ovale. The purpose of the presentation of this case report is, firstly, illustrating an entity which in very few occasions can be demonstrated by imaging tests, and secondly, making a brief review of the diagnosis and management of the patent foramen ovale as a part of the study of embolic sources.

A Case of Impending Paradoxical Embolism in a Pregnant Patient with Pulmonary Thromboembolism / 日本心臓血管外科学会雑誌

A 27-year-old woman who suffered loss of consciousness twice after left femoral pain in the 25th week of gestation was referred to the obstetrics and gynecology department of our hospital. A structure with an attachment on the atrial wall was found in both atria on echocardiography, leading us to suspect impending paradoxical embolism (IPE). Judging from the shape of the thrombus in the atria, we thought that there was a high possibility of further embolism although rescue of the baby was feasible via cesarean section, so we decided to carry out emergency surgery. After delivering the infant by cesarean section, we used a heart-lung machine to incise the right atrium under hypothermia and remove the thrombus. As intraoperative esophageal echocardiography showed embolization in the right pulmonary artery, we cut the right pulmonary artery and removed the emboli. After surgery, a femoral vein thrombus was observed on echocardiography of the lower extremity vein, and we inserted an inferior vena cava filter. The patient was discharged on the 16th postoperative day. The situation whereby a thrombus is trapped in the foramen ovale without embolism of the arterial system is the rare pathological condition known as IPE. As no cases of surgical thrombectomy to treat IPE arising from complications of pregnancy have been reported thus far, the case described herein fittingly augments the literature.

Embolismo paradojal- tromboembolismo pulmonar e isquemia cerebral por foramen oval permeable: reporte de caso / Paradoxical embolism - pulmonary thromboembolism and cerebral ischemia due to patent oval foramen: case report

El 30 a 40% de las enfermedades cerebrovasculares presentan un origen desconocido o criptogénico. Puede estar relacionado con la persistencia de foramen oval (FOP), cuya prevalencia es de 12 a 30%. Reportamos el caso de una paciente mujer de 62 años, que fue intervenida por tumoración de tiroides. En el postoperatorio presentó disnea, hipoxemia, compromiso de conciencia y afasia de expresión. La ecocardiografía transtorácica mostró dilatación de cámaras derechas y la ecocardiografía transesofágica reveló un foramen oval permeable (FOP) con la presencia de ecos compatibles con coágulos que bordeaban dicho orificio: la tomografía cerebral evidenció un infarto cerebral en el hemisferio izquierdo. El hallazgo de coágulos y del FOP en el intraoperatorio confirmó el desarrollo de tromboembolismo pulmonar y embolismo paradojal.

30 to 40% of cerebrovascular diseases are of unknown or cryptogenic origin; they may be related to patent foramen ovale (PFO) with a prevalence of 12 to 30%. We report the case of a 62 year old woman who underwent surgery for a thyroid tumor. In the postoperative period she presented dyspnea, hypoxemia, impaired consciousness and expression aphasia. Transthoracic echocardiography showed dilatation of right chambers, and transesophageal echocardiography revealed a patent foramen ovale (PFO) with the presence of echoes compatible with clots bordering this defect; the brain scan revealed a stroke in the left hemisphere. The presence of clots and PFO intraoperatively confirmed the development of pulmonary embolism and paradoxical embolism.

Clinical and imaging characteristics in cryptogenic ischaemic stroke with right-to-left shunt / 中国神经精神疾病杂志

Objective To investigate the clinical and imaging characteristics in cryptogenic stroke with right-to-left shunt (RLS). Methods Fifty-two patients with cryptogenic ischaemic stroke were included in the study and divided into two groups according to transcranial Doppler (TCD) bubble test: RLS group (twenty-five patients) and non-RLS group (twenty-seven patients). The demographic data, traditional risk factors of stroke and characteristics of le?sion patterns were compared between two subgroups. Results There was no significant difference between the groups in age or sex ratio. The percentage of patients with no risk factors was significantly higher in RLS group than non-RLS group (44%vs. 14.8%, P=0.015). The lesion was more frequently observed in the vertebrobasilar artery territory in RLS group (56%vs. 14.8%, P0.05). Conclusions Vertebrobasilar Stroke without traditional cerebrovascular risk factors is more likely to be RLS-associated, which requires an advanced TCD bubble test to find the potential cause of stroke.

Association of Left Atrial Enlargement with Cortical Infarction in Subjects with Patent Foramen Ovale / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Left atrial dysfunction has been reported in patients with patent foramen ovale (PFO). Here we investigated the role of left atrial dysfunction in the development of embolic stroke in patients with PFO. METHODS: We identified consecutive patients with embolic stroke of undetermined sources except for PFO (PFO+ESUS). Healthy subjects with PFO served as controls (PFO+control). A stratified analysis by 10-year age group and an age- and sex- matching analysis were performed to compare echocardiographic markers between groups. In the PFO+ESUS group, infarct patterns of PFO-related stroke were determined (cortical vs. cortico-subcortical) and analyzed in correlation with left atrial function parameters. RESULTS: A total of 118 patients and 231 controls were included. The left atrial volume indices (LAVIs) of the PFO+ESUS patients were higher than those of the PFO+controls in age groups of 40–49, 50–59, and 60–69 years (P28 mL/m2) LAVI was more associated with the cortical infarct pattern (P=0.043 for an acute infarction and P=0.024 for a chronic infarction, both adjusted for age and shunt amount). The degree of right-to-left shunting was not associated with infarct patterns, but with the posterior location of acute infarcts (P=0.028). CONCLUSIONS: Left atrial enlargement was associated with embolic stroke in subjects with PFO. Left atrial physiology might contribute to the development of PFO-related stroke and need to be taken into consideration for optimal prevention of PFO-related stroke.

Patent Foramen Ovale and Stroke-Current Status / 대한뇌졸중학회지

Patent foramen ovale (PFO) is growing in clinical interest because of a renewed focus on embolic stroke of undetermined source (ESUS), the PFO attributable fraction (the 10-point Risk of Paradoxical Embolism score), technical advances in PFO diagnosis, and the emergence of endovascular device closure as a treatment option. However, recent randomized controlled trials of the management of patients with ESUS and PFO failed to demonstrate the superiority of closure over medical treatment. The mechanisms of stroke other than paradoxical embolism may be important in patients with ESUS and PFO. This paper reviews the current understanding of the pathophysiology of stroke and therapeutic options in patients with PFO and ESUS.

Posterior Cerebral Artery Infarction in a Patient with Coexisting Hereditary Hemorrhagic Telangiectasia and Patent Foramen Ovale

Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk of developing pulmonary arteriovenous malformations (pAVMs). Paradoxical embolism may occur through pAVMs or patent foramen ovale (PFO) and lead to cerebral infarction. We present a case of cerebral infarction with both pAVM associated with HHT and PFO. Evidence of a right-to-left shunt can suggest other treatment options for stroke prevention, and patients without evidence of conventional stroke etiologies require a thorough evaluation.

Posterior Cerebral Artery Infarction in a Patient with Coexisting Hereditary Hemorrhagic Telangiectasia and Patent Foramen Ovale

Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk of developing pulmonary arteriovenous malformations (pAVMs). Paradoxical embolism may occur through pAVMs or patent foramen ovale (PFO) and lead to cerebral infarction. We present a case of cerebral infarction with both pAVM associated with HHT and PFO. Evidence of a right-to-left shunt can suggest other treatment options for stroke prevention, and patients without evidence of conventional stroke etiologies require a thorough evaluation.

Unusual paradoxical embolic stroke in a patient with persistent left superior vena cava / 영남의대학술지

Cardiogenic embolic stroke accounts for approximately 20% of ischemic strokes and the likelihood of its recurrence is high. Paradoxical embolism may be an important cause of cardioembolic stroke, which can be evaluated through multiple diagnostic modalities including transesophageal echocardiography (TTE) or transcranial Doppler. A persistent left superior vena cava (PLSVC) is a rare congenital vascular anomaly, which mainly drains to the right atrium via the coronary sinus. Although rare, PLSVC draining into the left heart predisposes the patient to paradoxical embolism through a right-to-left shunt. We report on a 78-year-old female patient with an ischemic stroke associated with PLSVC draining into the left atrium through the pulmonary vein, which was investigated via TTE with an agitated saline test and computed tomography.

Recurrent Embolic Stroke due to Atrial Septal Defect without Pulmonary Hypertension

No abstract available.

Paradoxical carbon dioxide embolism during laparoscopic cholecystectomy as a cause of cardiac arrest and neurologic sequelae: a case report / 대한마취과학회지

An 81-year-old male patient was scheduled for a laparoscopic cholecystectomy due to acute cholecystitis. About 50 minutes into the operation, the arterial blood pressure suddenly decreased and ventricular fibrillation appeared on the electrocardiography. The patient received cardiopulmonary resuscitation and recovered a normal vital sign. We suspected a carbon dioxide embolism as the middle hepatic vein had been injured during the surgery. We performed a transesophageal echocardiography and were able to confirm the presence of multiple gas bubbles in all of the cardiac chambers. After the operation, the patient presented a stable hemodynamic state, but showed weaknesses in the left arm and leg. There were no acute lesions except for a chronic cerebral cortical atrophy and chronic microvascular encephalopathy on the postoperative brain-computed tomography, 3D angiography and magnetic resonance image. Fortunately, three days after the operation, the patient's hemiparesis had entirely subsided and he was discharged without any neurologic sequelae.

Right-to-left shunt and the hypercoagulable state: does paradoxical embolism play a role in patients with antiphospholipid syndrome and stroke? / Shunt direita-esquerda e hipercoagulabilidade: embolia paradoxal pode ser responsável pelo AVC na síndrome antifosfolipídica?

OBJECTIVE: Patent foramen ovale is associated with paradoxical embolism (PE) and stroke. Hypercoagulable states, such as antiphospholipid syndrome (APS), can exacerbate PE by increasing clot formation. The aim of this study was to verify whether patients with APS and stroke present a right-to-left shunt (RLS) with greater frequency than patients with APS but without stroke. METHODS: Fifty-three patients with APS were tested for RLS using contrast-enhanced transcranial Doppler (cTCD): 23 patients had a history of stroke (Stroke Group) and 30 had no history of stroke (No-stroke Group). RESULTS: cTCD was positive in 15 patients (65%) from the Stroke Group and in 16 patients (53%) in the No-stroke Group (p=0.56). The proportion of patients with a small RLS (<10 high-intensity transient sign or HITS) and a large RLS (>10 HITS) was similar between the groups without significant difference. CONCLUSIONS: Our data do not support the theory that paradoxical embolism may play an important role in stroke in APS patients.

OBJETIVO: O forame oval patente está associado com embolia paradoxal e acidente vascular cerebral isquêmico (AVCi). Estados de hipercoagulabilidade, como a síndrome antifosfolipídica (SAF), podem facilitar esse processo, aumentando a formação de coágulos. O objetivo deste estudo foi verificar se pacientes com SAF e AVCi apresentam maior frequência de shunt direita-esquerda (SDE), comparados a pacientes com SAF sem AVCi. MÉTODOS: Cinquenta e três pacientes com SAF foram testados para SDE usando Doppler transcraniano contrastado (DTCc): 23 com AVCi (Grupo AVC) e 30 sem história de AVCi (Grupo Controle). RESULTADOS: DTCc foi positivo em 15 pacientes (65%) do Grupo AVC e em 16 pacientes (53%) no Grupo Controle (p=0,56). A proporção de pacientes com pequeno SDE (<10 HITS) e grande SDE (>10 HITS) foi semelhante nos dois grupos. Não houve diferença significativa entre os grupos. CONCLUSÕES: Nossos dados não sugerem que embolia paradoxal seja causa importante de AVCi em pacientes com SAF.

A Case of Cryptogenic Stroke Associated with Patent Foramen Ovale Coexisting with Pulmonary Embolisms, Deep Vein Thromboses, and Renal Artery Infarctions

A paradoxical embolism is defined as a systemic arterial embolism requiring the passage of a venous thrombus into the arterial circulatory system through a right-to-left shunt, and is commonly related to patent foramen ovale (PFO). However, coexisting pulmonary embolisms, deep vein thromboses (DVT), and multipe systemic arterial embolisms, associated with PFO, are rare. Here, we report a patient who had a cryptogenic ischemic stroke, associated with PFO, which is complicated with a massive pulmonary thromboembolism, DVT, and renal infarctions, and subsequently, the patient was treated using a thrombolytic therapy.

Thrombus in transit in a patient with ischaemic stroke

Stroke or cerebrovascular accident is common and is most commonly embolic or haemorrhagic. A common source of embolism is the heart and as such echocardiogram is an essential investigation. However, clinicians need to be aware of rare sources of embolism. We report a rare and interesting case of a 61-year-old Caucasian man who presented with stroke and on evaluation was found to have a large thrombus coiled striding over a patent foreman ovale into the right and left atrium consistent with a 'thrombus in transit'. The origin of the thrombus was later confirmed to be from the left saphenous vein. This case highlights an interesting case of 'thrombus in transit'.

Renal infarction caused by paradoxical embolism through a patent foramen ovale

A 48-year-old man presented with acute right flank pain. A computed tomography scan revealed right renal infarction. Because he had no thrombosis in the renal vessels and no clear embolic source, a further examination was performed to find the cause of the renal infarction. On transesophageal echocardiography, a right-to-left shunt during the Valsalva maneuver established a diagnosis of patent foramen ovale. This is a case of paradoxical embolism through a PFO leading to renal infarction.