Cerebral hemorrhagic infarction as the initial manifestation of deep venous thrombosis in a child with patent foramen ovale

Arterial ischemic stroke (AIS), with an estimated incidence of 1.1–4.3 per 100,000, is an important cause of morbidity and mortality in children and the risk of recurrence is high. We present the case of an 11-year-old child who presented with a symptomatology of acute ischemic stroke of unknown etiology. The radiological investigation did not reveal any underlying brain abnormality that could cause the event. The diagnostic work up included an echocardiogram, which revealed a thrombus in the right atrium, in conjunction with a patent foramen ovale. The patient was initiated immediately on anticoagulation therapy with low molecular weight heparin and warfarin, but two days later she suffered pulmonary emboli, diagnosed with spiral thorax computed tomography (CT) scan. An ultrasound study of the vessels of the lower extremities revealed deep venous thrombosis (DVT), which was considered to be the underlying causative mechanism.

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A deadly chain of events in a case; Deep venous thrombosis, pulmoner embolism, patent foramen ovale and cerebral embolism

Anadolu Kardiyoloji Dergisi/The Anatolian Journal of Cardiology ◽

10.5152/akd.2013.088 ◽

2013 ◽

Author(s):

Murat Eroglu ◽

Murat Yalcin ◽

Zafer Isilak ◽

Murat Velioglu

Keyword(s):

Venous Thrombosis ◽

Deep Venous Thrombosis ◽

Patent Foramen Ovale ◽

Cerebral Embolism ◽

Foramen Ovale

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Cerebral hemorrhagic infarction as the initial manifestation of deep venous thrombosis in a child with patent foramen ovale: A case report

International Journal of Case Reports and Images ◽

10.5348/ijcri-2017115-cr-10854 ◽

2017 ◽

Vol 8 (11) ◽

pp. 739

Author(s):

Dimitrios Panagopoulos ◽

Sofia Loukopoulou ◽

Georgios Markogiannakis ◽

Nikos Eleftherakis

Keyword(s):

Case Report ◽

Venous Thrombosis ◽

Deep Venous Thrombosis ◽

Patent Foramen Ovale ◽

Foramen Ovale ◽

Initial Manifestation ◽

Hemorrhagic Infarction

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Abstract 170: Role of Patent Foramen Ovale in First and Recurrent Childhood Cryptogenic Arterial Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.170 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Evelyn K Shih ◽

Shobha Natarajan ◽

Christine Falkensammer ◽

Lauren A Beslow ◽

Steven R Messe ◽

...

Keyword(s):

Ischemic Stroke ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Stroke Recurrence ◽

Atrial Septal Aneurysm ◽

Control Analysis ◽

Foramen Ovale ◽

Arterial Ischemic Stroke ◽

Stroke Patients ◽

Retrospective Case

Background: Numerous studies in adults have reported a robust association between patent foramen ovale (PFO) and cryptogenic arterial ischemic stroke (AIS), particularly in younger adults. The association between PFO and stroke in children has not been well characterized and the clinical significance of identifying a PFO in a child with first or recurrent cryptogenic stroke is currently unknown. Methods: We performed a retrospective case control analysis of a 10-year prospectively enrolled cohort of children with acute AIS who underwent transthoracic echocardiogram (TTE) as part of their diagnostic evaluation. We compared PFO prevalence in children with cryptogenic stroke to those with known stroke etiologies and to non-stroke controls. We also assessed stroke recurrence risk in children with vs without PFO and assessed PFO features that may confer higher stroke risk. Results: Of 119 children with first-ever AIS, 59 had TTE available for central review, of which 17 were cryptogenic and 42 had a known cause. PFO prevalence was higher in the cryptogenic stroke group (X, 24%) compared to both the known stroke etiology group (Y, 6%, p = 0.05) and non-stroke controls (Z, 8%, p = 0.05). However, 2 year recurrence free survival rates in stroke patients with PFO did not differ from those without PFO (HR 1.58, 95% CI 0.18-13.62, p = 0.68). PFOs in children with AIS vs controls had numerically more right-to-left shunt at rest (7 vs 0) and atrial septal aneurysm (4 vs 0) but the study was underpowered to look at these factors. Conclusions: In our prospectively enrolled cohort of children with AIS, we found the prevalence of PFO to be higher in children with cryptogenic stroke compared to healthy controls and non-cryptogenic stroke patients. The implication of PFO for risk of recurrence and optimal secondary preventative treatment remains uncertain and require further study.

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Abstract W MP64: Evaluation of Deep Venous Thrombosis in Cryptogenic Stroke and Patent Foramen Ovale

Stroke ◽

10.1161/str.45.suppl_1.wmp64 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Ava L Liberman ◽

Vistasp Daruwalla ◽

Deborah Bergman ◽

Richard A Bernstein ◽

Yvonne Curran ◽

...

Keyword(s):

Venous Thrombosis ◽

Deep Venous Thrombosis ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Chi Square ◽

Stroke Subtypes ◽

Contrast Enhanced ◽

Paradoxical Embolus ◽

Stroke Mechanism

Background and Purpose: In cryptogenic stroke (CS), paradoxical embolus has been suggested as a stroke mechanism. A prior study found a significant rate of pelvic deep venous thrombosis (DVT) using magnetic resonance venography (MRV). We sought to evaluate the yield of diagnostic tests for lower extremity (LE) and pelvic DVT in stroke patients with patent foramen ovale (PFO) and in the subset with CS. Methods: A single center retrospective study was performed to identify consecutive ischemic stroke or TIA patients with PFO who underwent contrast-enhanced 3D pelvic MRV imaging (Ablavar, Lantheus Medical Imaging, N. Billerica, MA) between 2009 and 2013 as part of an inpatient diagnostic evaluation. Results of pelvic MRV, LE Doppler ultrasound (US) as well as clinical data were abstracted. Ischemic subtype was retrospectively assigned using the Causative Classification System (CCS). Patients with possible cardio-aortic embolism and undetermined cause by CCS were classified as CS. We estimated point estimates and 95% confidence intervals (CI) for DVT prevalence among stroke subtypes using the Wald method and compared these using Chi-square tests. Results: Of 130 patients who met study criteria, mean age was 56 +/- 17 years and median time from admission to MRV was 2 days (IQR 1-3). Overall DVT prevalence was 7.7% (95% CI, 4.1 to 13.7); the prevalence of pelvic DVT was 1.6% (95% CI, 0.07 to 5.8) and that of LE DVT was 7.2% (95% CI, 3.7 to 13.3). Of the patients with pelvic DVT (n=2), one patient also had a LE DVT by US. When MRV or US was obtained within 72 hours following admission, the prevalence of pelvic DVT was 2.1% (95% CI, 0.12 to 7.7) and that of LE DVT was 7.8% (95% CI, 3.8 to 14.8). Comparing patients with CS (n=97) to other subtypes (n=33), there was no difference in the prevalence of pelvic DVT (2.1% vs. 0%, P=1), LE DVT (6.3% vs. 10.3%, P=0.43) or any DVT (7.2% vs. 9.1%, P=0.71). Conclusion: Patients with CS and PFO have similar prevalence of DVTs compared to other stroke subtypes. The majority of detected DVTs were in LE veins rather than pelvic veins. Only a single patient with a pelvic DVT did not have a coexistent LE DVT. Our results suggest that the utility of pelvic MRV may be much lower than previously reported.

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