RESUMO
A paradoxical embolism is defined as a systemic arterial embolus due to passage of a venous thrombus through a right to left shunt. We describe a case of acute cerebral vascular accident (CVA), right subclavian arterial embolus, and pulmonary emboli in the setting of a large patent foramen ovale (PFO). A 74-year-old woman with multiple comorbidities presented to the emergency department with acute onset of shortness of breath, weakness, and right arm pain. She was found to have bilateral pulmonary emboli, left CVA, and a right subclavian arterial embolus on computed tomography (CT). She emergently underwent embolectomy of her right upper extremity along with a fasciotomy. On chest CT, a PFO was visualized. Transesophageal echocardiogram (TEE) revealed a large PFO with at least a 3-mm primum/secundum separation and evidence of right to left shunting. Multidisciplinary consensus was that she would benefit from closure of her PFO in order to reduce her risk of further emboli. The patient was agreeable and taken to the catheterization lab where a sizing balloon over a stiff wire was advanced to measure the size of the defect. A 25-mm Cardioform device was successfully delivered across the defect. The patient was started on oral anticoagulation and antiplatelets. In summary, increase in right-sided pressures from pulmonary emboli can cause right to left shunting and lead to a paradoxical embolus. Assessment of patients who present with acute CVA or arterial embolus in the setting of pulmonary emboli with elevated right atrial pressures should include an evaluation for a PFO. Closure of PFO in these patients is of potential additive benefit.
RESUMO
The purpose of the study was to present our experience with endocranial fixation using the Resorb-X mesh (KLS Martin, Jacksonville, FL) in frontoorbital reconstruction. A retrospective review of all patients underwent frontoorbital advancement at our institution from 2003 to 2012 was performed. Inclusion criterion included: pediatric patients who underwent frontoorbital advancement for craniosynostosis; patients underwent treatment of the craniosynostosis only at our center; resorbable fixation devises were applied only endocranially; and follow-up was ≥ 2 years. Patients' evaluation included demographic information, postoperative complications, surgical outcomes, and postoperative computed tomographic imaging if accessible. Thirty-nine patients met the inclusion criteria. Resorbable plates were used in 16 patients and Resorb-X mesh in 23 patients. Observed complications were unrelated to the fixation system used. Resorption of fixation devices was evident in all patients after 20 months following reconstruction. There were no incidents of local reaction to the fixation system. Frontoorbital area contour was deemed good in 24 patients and excellent in 15 patients by both families and attending surgeon. There was a statistical significant difference (P = 0.030) between patients ≤ 12 months and >12 months regarding the complications rate. Endocranial fixation using the Resorb-X mesh is easily applicable, avoids material palpability, and provides stable and secure fixation. This technique is superior to the conventional endocranial osseous fixation with absorbable plates, as it avoids some of its possible complications while providing all the benefits of resorbable fixation.
