Unresponsiveness to Chiari Malformation Type I Surgery Can Be Related to the Accompanying Chiari Network.

Surgical treatment is indicated for Chiari malformation type 1 (CMI) with tonsillar descent (TD) of >5 mm and other clinical manifestations. However, some patients remain unresponsive to surgery; this is an active topic of discussion. A patient presented to the emergency department with dizziness and an impaired gait. He had a history of hypertension. Magnetic resonance investigations revealed a 9-mm TD and cervical syringomyelia. There was no evidence of interatrial septum pathology on transthoracic echocardiography performed preoperatively. Although his complaints were attributed to CMI and surgery was performed, his symptoms remained persistent. Two years later, when the patient's dizziness increased, a posterior fossa transient ischemic attack (TIA) was suspected. A large patent foramen ovale (PFO) and Chiari network (CN) were also detected on transesophageal echocardiography. His complaints were resolved following PFO closure. Our case suggests that neurosurgeons should be informed about the results of the companionship of a PFO and CN. Before deciding on CMI surgery for patients with only dizziness complaints, a detailed investigation of accompanying cardiac pathologies is paramount to ensure accurate diagnosis and treatment.

Increased Risk of Cryptogenic Stroke Associated with Patent Foramen Ovale in Young Adults.

Ischemic stroke is defined as a reduction in blood flow to brain tissue that results in the deterioration and death of neurons in a matter of minutes. While often seen in older patients with a history of atherosclerosis of the major arteries, a subset of ischemic strokes occur in younger individuals with minimal to no prior risk factors. Further evaluation of these unknown, or cryptogenic, strokes has yielded positive findings of a patent foramen ovale (PFO) in a concerning number of cases. Cryptogenic strokes attributable to PFO present an important clinical occurrence because they do not fit the typical template regarding those most at risk for such acutely devastating outcomes, making their identification uniquely important for both immediate and long-term patient care.  A 20-year-old Hispanic female presented to the emergency department for evaluation of neurological symptoms indicating obstruction of a major cerebral vessel. After being placed on stroke alert and found to have an embolus occluding the left middle cerebral artery (MCA) via non-contrast computed tomography (CT), tissue plasminogen activator (tPA) was administered, and mechanical thrombectomy was performed to restore blood flow. Following stabilization, further testing done on the patient revealed a substantial PFO that likely allowed for the crossing of an embolus from venous blood returning to the heart directly into the arterial circulation. The patient opted for cardiac monitor placement and has remained asymptomatic to this point while awaiting surgical repair. This case demonstrates an unusual presentation of ischemic stroke in a young individual with no reported risk factors and highlights the importance of screening for large PFO in patients prior to a serious cerebrovascular accident. It is our hope that highlighting this case may heighten awareness of this condition and allow for timely recognition from medical personnel who may encounter this same medical emergency in the future.

A Rare Case of Spontaneous Pneumothorax Leading to Cerebral Air Embolism.

Cerebral arterial air embolism (CAE), a rare subtype of air embolism, carries a 21% mortality rate. We present a unique case involving a 69-year-old female with a history of usual interstitial pneumonia (UIP) who suffered a transient ischemic attack (TIA) due to CAE. Unlike typical cases, CAE in this instance resulted from spontaneous pneumothorax, not the more common iatrogenic causes. Adding complexity, an unexpected discovery emerged during evaluation: a patent foramen ovale, contributing to paradoxical embolism. This underscores the vital need to consider CAE as a differential diagnosis in UIP patients with neurological symptoms, highlighting its rarity and diagnostic challenges.

Eustachian Valve-Enhanced Paradoxical Cerebral Embolism: A Case Report.

Cryptogenic stroke includes many suspicious embolic causes that do not fulfill the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification criteria. Atrial fibrillation (AF) is one of the major hidden causes of cryptogenic stroke, and an implantable loop recorder (ILR) is widely used for detecting AF. Herein, we report a case of paradoxical cerebral embolism due to a large Eustachian valve with large PFO under no molecular complete remission (CR) of acute monocytic leukemia (AMoL). A 75-year-old man arrived at our emergency room because of aphasia and right hemiparesis. He had a history of two cryptogenic strokes and implanted ILR. Magnetic resonance imaging showed left middle cerebral artery occlusion with slight acute ischemic lesion. The red clot was retrieved by mechanical thrombectomy, and complete recanalization was achieved. We checked ILR, but there was no AF. Transesophageal echocardiography revealed a large patent foramen ovale (PFO) and the large Eustachian valve in the right atrium. Although obvious deep vein thrombosis (DVT) was not detected in venous ultrasonography of the lower extremities, Wilms' tumor 1 messenger ribonucleic acid (WT1mRNA) expression level was high, and AMoL was considered to be not in molecular CR, suggesting a high risk of thrombosis to the large Eustachian valve. From large PFO and no molecular CR of AMoL, we diagnosed him with paradoxical cerebral embolism. Ruling out of AF by ILR and other etiologies, such as aortic or carotid atherosclerosis and pulmonary shunt, also supported the diagnosis of paradoxical cerebral embolism. Even in the absence of obvious DVT, paradoxical cerebral embolism should be considered in cases of a large Eustachian valve and PFO with a hypercoagulable state.

Transient ischemic attack induced by pulmonary arteriovenous fistula in a child: A case report.

BACKGROUND: Cerebral ischemic stroke is attributed to paradoxical cerebral embolism. Pulmonary arteriovenous fistula (PAVF) is a rare potential cause of cerebral ischemic stroke, and cerebral ischemic stroke induced by PAVF in children is rare. CASE SUMMARY: We report a case of right PAVF that presented as a transient ischemic attack (TIA) in a 13-year-old boy. The patient underwent embolization therapy and remained clinically stable for 2 years after treatment. CONCLUSION: TIA induced by PAVF in children is rare, lacks typical clinical manifestations, and should not be ignored.

A Case of Paradoxical Cerebral Embolism Due to Pulmonary Arteriovenous Fistula Mimicking Vertebral Artery Dissection With Wallenberg Syndrome.

Pulmonary arteriovenous fistula (PAVF) leads to paradoxical cerebral embolism, which can be fatal if left untreated. We report a rare case of brainstem infarction with acute severe headache and Wallenberg syndrome caused by a PAVF mimicking vertebral artery (VA) dissection. A 40-year-old man presented with a sudden occipital headache accompanied by right hemisensory disturbance. Magnetic resonance imaging revealed left lateral medullary infarction and poor depiction of the left VA. However, it was clearly recanalized on day six, and there were no findings of VA dissection. Whole-body contrast-enhanced computed tomography (CT) revealed a PAVF in the right lung and a thrombus in the feeding artery. The patient was diagnosed with hereditary hemorrhagic telangiectasia due to recurrent epistaxis and peripheral vasodilation of the tongue. An anticoagulant was administered for preventing further ischemic stroke, and a follow-up CT confirmed the disappearance of the thrombus in three months. Thoracoscopic partial lung resection was performed five months after the onset, and no recurrence of ischemic stroke was observed.

[A case of recurrent cerebral infarction in an adult patient with false Taussig-Bing anomaly].

The case was a 53-year-old woman. At birth, she was diagnosed with a false Taussig-Bing anomaly with pulmonary artery stenosis and a single ventricle. However, no cardiac surgery was performed, and conservative treatment was continued by a cardiovascular surgeon even after adulthood. Because of secondary polycythemia and a history of multiple cerebral infarctions, she took anti-platelet drugs and anti-coagulants. However, she was admitted with the diagnosis of cerebral infarction for the fourth time. It was considered that the patient was at high risk of paradoxical cerebral embolism due to cardiac malformation with cyanotic congenital heart disease accompanied by coagulation abnormalities. Considering the pathophysiology, we decided to use aspirin in combination with warfarin.

Clinical conundrum: concomitant high-risk pulmonary embolism and acute ischemic stroke.

High-risk PE can be complicated by the presence of a patent foramen ovale (PFO), which can lead to paradoxical systemic embolization, including cerebral embolism ultimately leading to acute ischemic stroke (AIS). Acute management is challenging given the competing benefits and risks of systemic thrombolysis. Herein, we aim to provide a review of clinical presentations, diagnostic findings, and treatment and outcome from the available literature, with the hopes of providing insight into treatment options. We followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic literature search using PubMed/MEDLINE database, Cochrane Library, and Google Scholar for all reported cases/case series of concomitant high-risk PE and paradoxical ischemic stroke was conducted from inception to July 2019. Twenty-nine cases from 27 articles (26 single case reports, 1 case series of 3 patients) were included. There were 10 men and 19 women, ranging in age from 29 to 81 years (mean 56.1 ± 13.5 years). PFO was diagnosed in 89.7% of patients, mostly by transesophageal echocardiography. Treatment modalities included systemic thrombolysis (40%), anticoagulation alone (36%), surgical thrombectomy (16%), and percutaneous thrombectomy (8%). Overall mortality rate was 31%. Patients receiving thrombolysis and surgical thrombectomy had the most favorable outcome. Survival to discharge was 90% (9 out of 10), 100% (5 out of 5), and 50% (4 out of 8) in the systemic thrombolysis, surgical thrombectomy, and anticoagulation alone groups respectively. In the setting of combined high-risk PE and ischemic stroke, PFO can be detected in 90% of published cases. Thrombolysis and surgical thrombectomy seem to be effective management, but further studies are needed for validation.

A Case of Hereditary Hemorrhagic Telangiectasia Suspected due to Anemia during Anticoagulation Therapy after Thrombectomy.

Objective: Hereditary hemorrhagic telangiectasia (HHT) may be associated with paradoxical cerebral embolism caused by pulmonary arteriovenous malformation (PAVM). We present a case of HHT diagnosed by progressive anemia during anticoagulant therapy following mechanical thrombectomy. Case Presentation: The patient was a 59-year-old woman who presented with acute stroke due to intracranial large vessel occlusion. Mechanical thrombectomy was successfully performed and the thrombus was retrieved. Postoperatively, anticoagulant therapy was started; however, she developed progressive anemia, which was associated with marked weakness, although no bleeding source was detected. Thorough postoperative imaging studies revealed PAVMs, which may be a source of cerebral embolism. It was noted that she frequently had episodes of epistaxis and a family history of PAVM. Embolization of PAVMs was performed to prevent the recurrence of embolic disorders. After this procedure, anticoagulant therapy was safely discontinued, which resulted in the improvement of anemia. Conclusion: Physicians need to consider the possibility of HHT associated with PAVM which can cause paradoxical cerebral embolism.

Paradoxical Cerebral Embolism as Initial Manifestation of Chronic Thromboembolic Pulmonary Hypertension: A Case Report.

Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by chronic thrombi in the pulmonary arteries, causing pulmonary hypertension and right heart failure. Early and accurate diagnosis are essential for successful treatment but are often difficult because clinical signs and symptoms can be nonspecific and risk factors, such as history of venous thromboembolism, may not always be present. Here, we report a case involving a 76-year-old woman who demonstrated paradoxical cerebral embolism as the initial manifestation of CTEPH. She developed right hemiplegia without dyspnea or edema. Brain magnetic resonance imaging revealed multiple fresh infarctions, while transesophageal echocardiography revealed a patent foramen ovale. Based on these findings, she was diagnosed as having paradoxical cerebral embolism. During the search for the embolic source, right heart catheterization showed significant pulmonary hypertension and pulmonary angiography revealed chronic thrombi in the peripheral pulmonary arteries, consistent with a diagnosis of CTEPH. To our knowledge, this is the first case of CTEPH to be diagnosed with the onset of paradoxical cerebral embolism. Because CTEPH is the only potentially curable form of pulmonary hypertension, clinicians should consider paradoxical cerebral embolism as a possible initial manifestation of CTEPH.

Pediatric Acute Paradoxical Cerebral Embolism with Pulmonary Embolism Caused by Extremely Small Patent Foramen Ovale.

Herein, we report a pediatric case of acute paradoxical cerebral embolism complicated by serious acute pulmonary embolism that was caused by an extremely small patent foramen ovale (PFO). The patient had no medical history suggestive of any other reason. Paradoxical cerebral embolism may occur even with an extremely small PFO because of the increased right-side pressure of the heart and a resulting right-to-left shunt from the acute pulmonary embolism. Although pediatric cases of pulmonary embolism are rare, when diagnosed, clinicians should consider the risk of a concurrent paradoxical cerebral embolism resulting from a latent PFO. The possibility of PFO should be assessed extremely carefully in pediatric critical care by checking for a thrombogenesis tendency and the existence of deep vein thrombosis in the patient.

Port-Access Minimally Invasive Cardiac Surgery for Patent Foramen Ovale Complicated with Paradoxical Cerebral Embolism / 日本心臓血管外科学会雑誌

The patient was a 63-year-old man, who had developed cerebral infarction during treatment for sleep apnea syndrome. He also presented typical features of deep venous thrombosis of the right lower extremity. Transesophageal echocardiography clearly showed the blood flow passing through the patent foramen ovale (PFO) followed by Valsalva maneuver. Paradoxical cerebral embolism caused by a PFO was diagnosed. Several procedures were considered to prevent recurrence of cerebral infarction, he underwent PFO closure by minimally invasive procedure, so-called port-access cardiac surgery. He started walking on the day of surgery, and postoperative echocardiography showed no residual shunt flow. Currently, no catheter-based PFO closure device is allowed in Japan, the PFO closure by the port-access technique should be considered as a feasible alternative.

Clinical analysis of paradoxical cerebral embolism from pulmonary embolism / 中华急诊医学杂志

Objective To explore the diagnosis and treatment of cerebral embolism from pulmonary embolism (PE).Methods The clinical data of 5 cases with PE accompanied by cerebral embolism covering a period from October of 2007 to July of 2011 were retrospectively analyzed.Results In this study,the average age of 5 cases (all female) was 46.5 years old.PE was diagnosed through enhanced CT and ECT in lung among all 5 cases.Moderate to severe pulmonary hypertension was confirmed by echocardiogram.Two cases was patent foramen ovale and one was congenital atrial septal defect.Each patient was diagnosed to be new-onset cerebral infarction by MRI.Three cases underwent cerebral arterial thrombolysis.All of them survived and long-term anticoagulant treatment with Warfarin.INR was adjusted between 2.0 and 2.5 by change of Warfarin dose.Among them,one patient had cerebral embolism again just 3 days after the latest cerebral embolism; the other 4 patients did not suffer from cerebral embolism during the follow-up.Conclusions Paradoxical cerebral embolism is common.For clinical patients with PE,especially pulmonary hypertension accompanied by systemic circulation arterial embolism or unexplained systemic cerebral arterial embolism,paradoxical cerebral embolism should be considered.