Brain-to-Brain Paradoxical Embolism through Patent Foramen Ovale after Cerebral Vein Thrombosis

The purpose of this article is to address several challenging questions in the management of young patients (those age 60 and under) who present with ischemic stroke. Do genetic thrombophilic states, strongly associated with venous thrombosis, independently cause arterial events in adults? Should cases of patent foramen ovale be closed with mechanical devices in patients with cryptogenic stroke? What are the optimal treatments for cerebral vein thrombosis, carotid artery dissection, and antiphospholipid syndrome and are DOACs acceptable treatment for these indications? What is the mechanism underlying large vessel stroke in patients with COVID-19? This is a narrative review. We searched PubMed and Embase and American College of physicians Journal club database for English language articles since 2000 looking mainly at randomized clinical trials, Meta analyses, Cochran reviews as well as some research articles viewed to be cutting edge regarding anticoagulation and cerebrovascular disease. Searches were done entering cerebral vein thrombosis, carotid dissection, anticoagulation therapy and stroke, antiphospholipid antibody and stroke, stroke in young adults, cryptogenic stroke and anticoagulation, patent foramen ovale and cryptogenic stroke, COVID-19 and stroke.

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Ischemic Stroke Due to Paradoxical Embolism in a Patient with Patent Foramen Ovale, Bilateral Distal Deep Vein Thrombosis and Platypnea-Orthodeoxia Syndrome: A Case Report

World Journal of Cardiovascular Diseases ◽

10.4236/wjcd.2021.1110045 ◽

2021 ◽

Vol 11 (10) ◽

pp. 477-483

Author(s):

Viola Tallarico ◽

Rossella Loiacono ◽

Silvia Gianstefani ◽

Giovanni Maria Puddu ◽

Paola Forti ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Ischemic Stroke ◽

Case Report ◽

Patent Foramen Ovale ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Vein Thrombosis ◽

Distal Deep Vein Thrombosis ◽

Deep Vein

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Aortogenic Embolism and Paradoxical Embolism due to Patent Foramen Ovale and Deep Vein Thrombosis(1. Systemic Complications Neurosurgeons need to Know,Stroke as a Systemic Vascular Disease)

Japanese Journal of Neurosurgery ◽

10.7887/jcns.17.901 ◽

2008 ◽

Vol 17 (12) ◽

pp. 901-908

Author(s):

Kazuo Kitagawa

Keyword(s):

Deep Vein Thrombosis ◽

Vascular Disease ◽

Patent Foramen Ovale ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Systemic Complications ◽

Vein Thrombosis ◽

Deep Vein

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May-Thurner Syndrome as a Rare Cause of Paradoxical Embolism in a Patient with Patent Foramen Ovale

Case Reports in Cardiology ◽

10.1155/2018/3625401 ◽

2018 ◽

Vol 2018 ◽

pp. 1-3

Author(s):

Dominika M. Zoltowska ◽

Guramrinder Thind ◽

Yashwant Agrawal ◽

Vishal Gupta ◽

Jagadeesh Kumar Kalavakunta

Keyword(s):

Magnetic Resonance ◽

Transient Ischemic Attack ◽

Patent Foramen Ovale ◽

Iliac Vein ◽

Paradoxical Embolism ◽

Common Iliac Vein ◽

Foramen Ovale ◽

Anatomical Variant ◽

Vein Thrombosis ◽

Ischemic Attack

May-Thurner syndrome is an underrecognized anatomical variant that can lead to increased propensity for venous thrombosis in the lower extremities. We present a case of a 67-year-old female who presented with transient ischemic attack. Initial workup including CT scan of the head, MRI scan of the head, and magnetic resonance angiogram of the head and neck was unremarkable. A transthoracic echocardiogram with bubble study was also normal. Subsequently, a transesophageal echocardiogram was performed that revealed a patent foramen ovale with right-to-left shunt. Lower extremity duplex venous ultrasound showed no evidence of deep vein thrombosis. However, magnetic resonance venogram of the pelvis showed compression of the left common iliac vein just after its origin suggestive of May-Thurner syndrome. Hence, May-Thurner syndrome was recognized as the probable source of paradoxical embolism causing transient ischemic attack in this patient.

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Multiorgan paradoxical embolism in an elderly female with a patent foramen ovale: a case report

Medicine and Pharmacy Reports ◽

10.15386/cjmed-1031 ◽

2019 ◽

Vol 92 (1) ◽

pp. 83-86 ◽

Cited By ~ 1

Author(s):

Dimitrios Anyfantakis ◽

Paraskevi Karona ◽

Pagona Kastanaki ◽

Athanasios Kourakos ◽

Miltiades Kastanakis

Keyword(s):

Patent Foramen Ovale ◽

Arterial Occlusion ◽

Systemic Circulation ◽

Paradoxical Embolism ◽

Adverse Outcomes ◽

Current Evidence ◽

Foramen Ovale ◽

Vein Thrombosis ◽

Initiation Of Therapy ◽

Deep Vein

Paradoxical embolism is an uncommon cause of arterial occlusion with a high mortality burden. Current evidence suggests that patent foramen ovale is the most important etiological factor of paradoxical embolism, by acting as a pathway for a thromboembolic material originating from the peripheral veins, passing through the lungs and entering the systemic circulation. Here we present a case of paradoxical embolism in the mesenteric and renal arteries associated with pulmonary embolism and deep vein thrombosis in an elderly woman with no predisposing risk factor. A diagnosis of paradoxical embolism was considered and the presence of a patent foramen ovale was consequently confirmed with a transesophageal echocardiography. Urgent thrombolysis saved the life of the patient. Paradoxical embolism represents an emergency and therefore prompt diagnosis and initiation of therapy may prevent adverse outcomes.

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Abstract WP362: Over-Utilization of Studies to Detect Deep Venous Thrombosis in Stroke Patients With Patent Foramen Ovale

Stroke ◽

10.1161/str.51.suppl_1.wp362 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sophie Samuel ◽

Thuy Nguyen ◽

Sujan T Reddy ◽

Kaushik N Parsha ◽

Sean I Savitz

Keyword(s):

Ischemic Stroke ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Young Group ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Old Patients ◽

Vein Thrombosis ◽

Multivariable Regression ◽

Deep Vein

Introduction: Cryptogenic stroke may result from paradoxical embolism through a patent foramen ovale (PFO). However, the association between deep vein thrombosis (DVT) and cryptogenic stroke has not been proven. The objective of our study is to compare the incidence of DVT in young and old patients who presented with acute ischemic stroke and were found to have a PFO. Method: We conducted a single-centre retrospective study from January 2014-December 2018. Patients over the age of 18 with ischemic stroke and PFO, who underwent magnetic resonance venography (MRV) of the pelvis and venous doppler ultrasonography (VDU) for assessment of DVT were included. Primary endpoint was the incidence of DVT in patients that were age ≤ 60 (young group) compared to those age > 60 (old group). We further analyzed the incidence of DVT in cryptogenic stroke vs determined origin; and based on the Risk of Paradoxical Embolism (ROPE) score. Results: We included 327 patients: 200 were young (Y) and 127 were old (O). Incidence of DVT was similar for patients in Y versus those in O group (7% vs 8%). A significantly higher ROPE score ≥ 6 was seen in the Y group (71% vs 9%; p<0.001). However, there was no difference in the incidence of DVT in patients with high (9%) or low ROPE scores (8%); OR 0.75, 95% CI (0.32-1.76) p=0.517. Among cryptogenic stroke with high ROPE score and young, incidence of DVT was (7% vs 9%) in determined origin; OR 0.74, 95% CI (0.28-1.96) p=0.557. MRV pelvis detected a clot in 5% of all patients. In a multivariable regression analysis; age, gender, and presence of PFO was not associated with the incidence of DVT. Length of stay and mRS at day 7 were the same between Y and O groups. Conclusions: Detection of DVT was not associated with PFO, high ROPE scores or cryptogenic strokes. Our data indicate an over-reliance of testing for DVT, particularly MRV pelvis with contrast, in patients with PFO. Clinical studies are needed to identify other factors predictive of DVT in patients with ischemic stroke and PFO.

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