Search

We present a case report of a patient with acute upper and lower limb ischemia due to paradoxical embolism. A 67-year old woman without history of venous thromboembolism suffered dislocated patellar fracture requiring surgery in November 2017. Two months after surgery she presented to the emergency room with bilateral pulmonary embolism, occlusion of the left subclavian artery, left common femoral artery and superior mesenteric artery. Transesophageal echocardiography detected patent foramen ovale. Vascular surgeon decided against embolectomy, interventional radiologist against pharmacomechanical thrombolysis due to the extent of the occlusions. Systemic thrombolysis (alteplase) was administered successfully with resolution of the emboli in the left subclavian artery, left common femoral artery and superior mesenteric artery.

Pulmonary arteriovenous fistula (PAVF), a vessel malformation connecting the pulmonary circulation to the systemic circulation while bypassing the pulmonary capillaries, can cause paradoxical cerebral infarction. It is often associated with hereditary hemorrhagic telangiectasia (HHT), a genetic disease characterized by multiple dermal, mucosal, and visceral telangiectasia causing recurrent bleeding. Paradoxical cerebral embolism caused by PAVF without HHT is rare. Here, we report a patient with isolated PAVF who experienced an ischemic stroke caused by a paradoxical embolism from deep venous thrombosis; the patient was successfully treated with recombinant tissue plasminogen activator. She presented with a decrease in arterial oxygen saturation to 91%, and lung disease was suspected. A PAVF was subsequently found in the right S6 region using contrast computed tomography. Interventional radiologists successfully occluded the shunt using 6 microcoils. PAVF should be considered when determining the pathogenesis of cerebral ischemia in patients with hypoxia, which can be the only symptom of PAVF., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Although patent foramen ovale (PFO) is a relatively common condition, the risk of paradoxical embolism is less than 2% of all arterial ischemia. We present the case of a 52-year-old man diagnosed with pulmonary thromboembolism complicated with 2 events of paradoxical emboli in the left upper and right lower limbs secondary to PFO. We also discuss some uncertainties behind the management of PFO patients after an episode of venous thromboembolism., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Development of paradoxical cerebral embolism requires both unstable venous thrombosis and right-to-left shunt (RLS). Gastrointestinal endoscopy (GE) has the potential to affect intrathoracic and abdominal venous thrombi and to enhance RLS because the procedure alters intrathoracic and abdominal pressure. We describe a patient with Crohn's disease who developed paradoxical cerebral embolism after GE. Both an unstable venous thrombus in the superior vena cava and RLS through patent foramen ovale were thought to be responsible for the stroke. Considering that patients with digestive system diseases undergo GE as a routine examination or therapy, screenings for hypercoagulable state and intrathoracic and abdominal thrombi are important to prevent thromboembolism related to GE., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

A 51-year-old man was diagnosed with eosinophilic granulomatosis with polyangiitis 6 years ago due to asthma, sinusitis, hypereosinophilia, and peripheral neuropathy based on the diagnostic criteria of American College of Rheumatology, and corticosteroid therapy achieved a remission. One year ago, he was hospitalized due to deep venous thrombosis (DVT) and pulmonary embolism, and rivaroxaban was administrated. He was admitted to our hospital for acute onset of diplopia and right hemiparesis. Peripheral blood examinations disclosed leukocytosis with hypereosinophilia. Perinuclear anti-neutrophil cytoplasmic antibodies were positive. Diffusion-weighted imaging showed multiple fresh ischemic lesions. Chronic ischemic lesions were seen in subcortical cerebral region. No stenosis or occlusion was shown in extracranial and intracranial arteries on magnetic resonance angiography. Ultrasonography of leg vein showed DVT. Right-to-left shunt through patent foramen ovale after Valsalva maneuver was seen on transesophageal echocardiography. Treatment with corticosteroid and cyclophosphamide alleviated clinical deterioration. Rivaroxaban was changed to warfarin. Diplopia and muscle strength of right limbs were improved. This is a first case of multiple cerebral infarction caused by paradoxical embolism due to patent foramen ovale with DVT based on hypercoagulable state of hypereosinophilia. Overall this case illustrates that eosinophilic granulomatosis with polyangiitis can be a risk factor for multiple cerebral infarction in the systemic phase and that transesophageal echocardiography and ultrasonography of leg vein should be conducted in stroke patient with eosinophilic granulomatosis with polyangiitis., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Although foam sclerotherapy to varicose veins is now a popular treatment because of its high efficacy and safety, some neurologic complications have recently been reported. Presently, the effectiveness and safety of intravenous recombinant tissue-type plasminogen activator therapy to stroke following foam sclerotherapy remain unclear. Here, we report the case of a 68-year-old woman whose ischemic symptoms following foam sclerotherapy were treated by intravenous recombinant tissue-type plasminogen activator. After she was admitted, the venous thrombosis in her right soleus vein and a patent foramen ovale causing the right-to-left shunt were revealed. Thus, we diagnosed the ischemic symptoms were due to paradoxical embolism following foam sclerotherapy. After intravenous recombinant tissue-type plasminogen activator therapy, there was no complication and the outcome was good. Our case suggests the effectiveness and the safety of intravenous recombinant tissue-type plasminogen activator therapy to paradoxical embolism following foam sclerotherapy., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

A 59-year-old woman presented with a sudden onset of breathlessness and chest pain. An echocardiography and CT scan showed pulmonary embolism and infarction with a paradoxical thrombus visualised in both atria. For haemodynamically stable patients, the optimal management strategy is poorly defined. Three main strategies were considered: surgical thrombectomy, thrombolysis and anticoagulation. Surgery with reversal of anticoagulation may lead to further coagulation and increased risk of bleeding complications. The significant pulmonary hypertension and right ventricular infarction raised the prospect of difficult weaning from cardiopulmonary bypass following thrombectomy. Thrombolysis, which has significant mortality rate, and systemic embolisation including pulmonary infarction with haemorrhagic transformation were also contraindications. A multidisciplinary approach was adopted and anticoagulation was therefore believed to be the safest and effective approach. Here, the use of anticoagulation alone was fortunately successful but could as easily end in disaster. This approach should be considered the ideal paradigm to yield optimum outcomes., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Rationale: The differential diagnosis of acute chest pain is very important, and can sometimes be challenging. Related diseases share a number of risk factors, and occasionally, 1 condition causes another disease to develop., Patient Concerns: We described a 59-year-old man who presented to emergency department complaining of chest pain., Diagnoses: He was suffered acute myocardial infarction (MI) and pulmonary embolism (PE) simultaneously., Interventions: Dual antiplatelet therapy, statin, and low molecular weight heparin were administrated during his stay. The searches for cancers, autoimmune diseases, and hematologic diseases were unremarkable, ruling out a hypercoagulable state. Subsequent ultrasound scan revealed a thrombus in a vein of the lower left extremity. Thus, paradoxical embolism was highly suspected., Outcomes: Paradoxical embolism is a rare cause of acute MI, which may have occurred in our patient. This was evidenced by a previously unrecognized patent foramen ovale (PFO) with a right-to-left atrial shunt detected using contrast transesophageal echocardiography., Lessons: Acute MI complicated with PE is not common in the clinical setting. The fatal condition is difficult to diagnose because of the similar symptoms and confusing causes. Paradoxical embolism can cause this phenomenon, and physicians should be highly vigilant in the search for a PFO in cases of paradoxical embolism., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Paradoxical embolism is a kind of important pathogenesis of cardiocerebrovascular diseases. In our case, radiofrequency current catheter ablation was accomplished successfully in a 15-year-old girl who had been experiencing supraventricular tachycardia for 6 months. She presented with abrupt onset of left hemiplegia and loss of consciousness on the first postoperative day. An urgent cerebral computed tomography showed a hyperdense right middle cerebral artery. Transthoracic echocardiogram examination revealed an atrial septal defect (ASD), with the diameter measuring 39 mm. The case highly suggests that the issue of ASD should be resolved by either closed or prompt anticoagulant therapy, especially for patients who are planned to receive catheter manipulation., (Copyright © 2017. Published by Elsevier Inc.)

Rationale: Paradoxical embolism (PDE) refers to direct passage of venous thrombi into the arterial circulation through an arteriovenous shunt., Patient Concerns: Case 1 presented with initial symptoms of shock and cerebral infarction. Case 2 developed middle cerebral artery occlusion during angiography., Diagnoses: 2 cases were diagnosed as PDE., Interventions: They received thrombolytic therapy and anticoagulant therapy., Outcomes: The patients had recovery., Lessons: This report highlights the myriad clinical manifestations of PDE and underlines the importance of meticulous history taking and physical examination for early diagnosis.

Cardioembolism is an important cause of ischemic stroke, with several studies showing worse outcome than following other stroke subtypes. Paradoxical embolism is a rare cause of cardioembolic stroke. We report a case of a patient with presumed paradoxical cardioembolic stroke secondary to thrombus formation on the eustachian valve remnant in the right atrium. The patient was anticoagulated with resolution of the mass upon follow-up assessment. The diagnostic, investigative and management strategies are discussed for patients with suspected paradoxical embolism causing stroke. Physicians are reminded of the utility of echocardiography for identifying potential cardioembolic etiologies, including both transthoracic and transesophageal echocardiography., (© 2015, Wiley Periodicals, Inc.)

Background: Pivotal clinical trials suggest that intravenous (IV) recombinant tissue plasminogen activator (rt-PA) benefits stroke patients regardless of the underlying etiology. Paradoxical strokes, presumed to be caused by fibrin-rich clots originating in the venous circulation, may respond better to fibrinolysis than other ischemic stroke subtypes. In this study, we compared the response with IV rt-PA in paradoxical stroke patients and other stroke subtypes., Methods: In total, 486 patients treated with IV rt-PA at a single institution were retrospectively reviewed. Adjudication of stroke mechanism was based on chart review. Five major stroke mechanisms--cardioembolic, artery-to-artery emboli, lacunar, cryptogenic, and paradoxical--were identified by final diagnosis from chart reviews. Mimics, undefined etiology, and defined etiology not falling into the major mechanisms were excluded. Analysis of variance and general linear model were used to assess the differences between groups., Results: A total of 323 patients were analyzed. We found significant differences in clinical outcome between stroke mechanisms, including discharge National Institutes of Health Stroke Scale (NIHSS) (P=.007), discharge Rankin (P=.011), discharge disposition (P=.000), and infarct volume (P=.007). Post hoc analysis showed that cardioembolic patients had the worst outcomes (discharge NIHSS score 11.12±12.26), whereas paradoxical strokes had the best outcomes (discharge NIHSS score 3.67±4.90), but these did not approach statistical significance. However, regression analysis showed that 4 variables--congestive heart failure, admission NIHSS, age, and mean infarct volume--rather than stroke mechanism were the true predictors of poor outcome., Conclusions: Paradoxical strokes had better outcomes after IV fibrinolysis than other ischemic stroke subtypes, but this difference is attributable to younger age and milder stroke severity on presentation., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: A thrombus straddling a patent foramen ovale (i.e., impending paradoxical embolism) is a very rare event. Most cases have been reported at autopsy only after finding a patent foramen ovale and arterial emboli. Patent foramen ovale in the population is common., Objectives: The objective of this case report is to remind physicians that common presentations can have uncommon causes. Some of these uncommon causes are easy to find and may significantly change outcomes if treated early., Case Report: We present the case of a dyspneic patient with concomitant pulmonary embolism, deep vein thrombosis, and impending paradoxical embolism. Emergency Physicians should be aware that dyspnea may be the only initial symptom. Although dyspnea may be linked to a pulmonary embolus, it may not represent the entire clinical picture. A thrombus formed within a patent foramen ovale portends the possibility of a larger pulmonary embolus and an arterial embolus., Conclusion: Early detection of an impending paradoxical embolism may result in an improved outcome. Treatment choices consist of anticoagulation, thrombectomy, or thrombolysis. Choice of treatment is difficult but should be made quickly to reduce the possibility of adverse patient outcomes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Case 1: Facial and upper extremity weakness in a 16-year-old boy. Case 2: Hematochezia in a neonate. Case 3: bad body odor in a 13-year-old girl.

Arterial thrombosis is the leading causes of morbidity and mortality worldwide, whereas venous thrombosis is the most common preventable cause of hospital death. In either case, venous and arterial thrombosis should be considered autonomous entities, with only minor overlaps in terms of risk factors, predisposing conditions and pathogenesis. Besides the widespread perception of embolization originating from low-pressure venous system and triggering ischemic stroke or peripheral arterial occlusion, "paradoxical" thrombosis might also develop or occur within clinical or biological circumstances where the blood should be less predisposed to clot, and wherein this risk is mostly unpredictable or overlooked. In this article we review epidemiological evidence and potential pathogenetic mechanisms of paradoxical thrombosis developing during antithrombotic therapy with vitamin K antagonists and heparin (i.e. heparin-induced thrombocytopenia), or antiplatelet agents such as aspirin, glycoprotein IIb/IIIa inhibitors or clopidogrel, and mostly attributable to direct effect of the agent.

The pathogenesis of venous and arterial thrombosis is complex and multifaceted, entailing a multitude of risk factors, which only marginally overlap between the two vessels districts. Along with conventional and universally recognized risk factors, thrombosis might also develop as a consequence of unusual, atypical, unsuspected and even paradoxical conditions. Although the term "paradoxical embolism" is typically used to identify an embolization process that originates from the low-pressure venous system and may generate ischemic stroke or peripheral arterial occlusion through a cardiac or pulmonary shunt, there are additional clinical circumstances whereby the risk of thrombosis is surprising, unpredicted or even neglected. In this article we thereby analyze the prevalence, as well as the pathogenesis, of thrombosis associated with apparently paradoxical triggers such as during factor replacement therapy in haemophiliacs or in patients with von Willebrand disease; in patients with inherited clotting factor deficiencies especially involving factor XII, factor VII, fibrinogen; or in those with a prolonged activated partial thromboplastin time for the presence of lupus anticoagulant.

A 72 year-old woman was admitted with a one-week history of weakness, right limb pain and progressive breathlessness. Her blood pressure was 60/40 mmHg, ECG showed inverted T waves in the precordial leads and incomplete right bundle branch block (RBBB). Transthoracic echocardiography revealed a large serpentine mobile mass across the atrial septum and mitrale valve extending into the left ventricular cavity. The right ventricle was dilated and peak systolic tricuspid annular velocity (RV-Sm) was 6.5 cm/sn, indicate right ventricular systolic function was severely depressed. Transoesophageal echocardiography showed a large, mobile thrombus in the foramen ovale, extending into the left atrium and ventricle. As the patient was in a haemodynamically compromised condition, high dose rapid infusion of streptokinase was administered. However, the thrombus did not fully resolve with this intervention. Therefore, low dose continuous streptokinase infusion was administered for an additional 72 h resulting in full resolution of the lesion by the third day of therapy. The optimal management of impending paradoxical embolism remains unclear. Prolonged continuous thrombolytic infusion may be a option for patients who do not experience full resolution of high risk thrombi with conventional thrombolytic therapy., (Crown Copyright © 2011. Published by Elsevier B.V. All rights reserved.)

We describe a case report observed via an echocardiography of a venous thromboembolism (VTE) that crosses through the patent foramen ovale to the left atrium and is successfully treated with alteplase. This is a case report of a tertiary care hospital without cardiac surgery facilities. An 81-year-old female seeking medical attention for dyspnoea, arriving at hospital with hypoxaemia, hypotension and prerenal failure. A computed tomographic (CT) pulmonary angiography was carried out, revealing a VTE. A transesophageal echocardiography (TEE) was carried out, exposing emboli in the right cavities, said thrombus crossing through the patent foramen ovale to the left atrium. A systemic thrombolysis is carried out using alteplase which improves the patient's condition and results in the disappearance of thrombotic images in the various cardiac cavities. The evolution is positive and there is no evidence of embolic or haemorrhagic complications. When a paradoxical embolism is present, in the context of a serious VTE, carrying out thrombolysis could be a therapeutic option.

Pulmonary embolus and right atrial thrombus trapped in a patent foramen ovale is an unusual, rare condition. We report a case of impending paradoxical embolism with pulmonary embolism, in which a thrombus entrapped in a patent foramen ovale was detected. To our knowledge, this is the first case in the literature in which 'thrombus-in-transit' was detected in the right atrium both before and after entrapment in a patent foramen ovale.

Economy class stroke syndrome consists of ischemic stroke due to paradoxical embolism through patent foramen ovale after a long flight. Few cases have been described in the literature to date. The treatment choice could be tricky. We present the case of a 65-year-old woman, admitted for submassive pulmonary embolism after a long flight, that presented a paradoxical embolic stroke through patent foramen ovale shortly after. The patient was treated with intravenous thrombolysis within 1 h of stroke onset with a definite symptoms improvement. Afterwards, intravenous unfractioned heparin was started with strict partial thromboplastin time monitoring. Cerebral computed tomography scan, obtained after 24 and 72 h, ruled out hemorrhage. Warfarin was started after 72 h. Patent foramen ovale was percutaneously closed 3 months after. In the reported case, the treatment with thrombolysis and subsequent heparin infusion was effective and safe. We discuss the rationale for this treatment in the light of literature data.

A patent foramen ovale (PFO) is detected frequently by transesophageal echocardiography. The diagnosis of paradoxical embolism is usually presumptive when arterial emboli occur in the appropriate clinical setting. Presumably, paradoxical embolism of small thrombi arise in the venous system and pass through the PFO during a transient right-to-left shunt; however, cases demonstrating a thrombus traversing the PFO are relatively few.

Paradoxical embolus is a rare complication of thrombolysis. With a high prevalence of clinically silent septal defects and widespread use of thrombolysis, recognition of the risks, clinical signs and symptoms is important. A case is reported of paradoxical embolus following thrombolysis in a woman with a previously undiagnosed patent foramen ovale.

Cystic fibrosis patients with an implantable venous access device (IVAD) and a patent foramen ovale (PFO) are at an increased risk of developing paradoxical embolism. A 33-year-old patient who had a cerebrovascular accident in the above setting is described. She had been anticoagulated because she had thrombosis of the tip of the indwelling catheter, and her PFO was closed percutaneously followed by replacement of her IVAD. She made a full neurological recovery. Echocardiography and prophylactic closure of the PFO, when present, as primary prevention for paradoxical embolism may be warranted in cystic fibrosis patients before placement of an IVAD.

A 79-year-old right-handed woman was admitted to hospital following sudden onset of severe visual loss in the left eye. Left central retinal artery occlusion (CRAO) was diagnosed. Diffusion-weighted imaging showed an asymptomatic hyperintensity in left middle cerebral artery territory. Transcranial Doppler and transesophageal echocardiography revealed patent foramen ovale. No other embolic sources were identified in the carotid artery, aortic arch, or heart. We report herein a case of CRAO caused by paradoxical brain embolism.

A case of a patient who presented with massive pulmonary embolism (PE) requiring thrombolysis with alteplase is reported. The subsequent presence of a patent foramen ovale and paradoxical embolism clinically demonstrated the speed of action of the recombinant tissue plasminogen activator. The advantage of this class of medication when considering the treatment options for a PE in an acute setting is highlighted.

When thrombotic material that originates from deep venous thrombosis of the lower extremities is washed out into the pulmonary vasculature, pulmonary embolization occurs. Pulmonary embolism and associated acute peripheral ischemia suggest the diagnosis of paradoxic embolism, which is most often associated with a patent foramen ovale. Therapeutic options include anticoagulation, mechanical/chemical thrombus dissolution, inferior vena cava filtration, and closure of the intracardiac defect. The diagnosis and treatment are described of an elderly female who presented with lower extremity deep venous thrombosis and massive pulmonary embolism complicated by paradoxic emboli to the left subclavian artery as well as the celiac artery.

We describe a case of impending paradoxic embolism in a 35-year-old woman who had a diagnosis of metastatic breast carcinoma. The patient presented with acute pulmonary embolism and was treated with anticoagulation therapy without any sign of a clinical embolic event.

Although paradoxical brain embolism result in the right-to-left shunt (RLS) is very important etiology of ischemic stroke especially in young adults, the detailed characteristics of them in Japan remain unknown. In collected clinical data for 7,245 acute stroke patients, patent foramen ovale (PFO) were more frequent in the young patients group (n = 1,584) than in the non-young patients group (n = 5,661) (0.7% vs. 1.2%, p = 0. 07). The frequency of PFO was rare than that of previously reported. Suspected reason is that the limited patients were underwent transesophageal echocardiography (TEE). The golden standard to detect RLS is contrast-enhanced TEE, and standardization of procedure is the most important factor. In our hospital, positive rate of RLS was risen up to 21.9% from 8.8% by standardization. In the patients with RLS in our hospital, the definite and probable criteria of paradoxical brain embolism were fulfilled only in 7.7% and 38.5%, respectively. If patients have any other risk factors (e.g. venous thrombus, cardiac source of embolism), to prevent recurrent stroke associated with RLS they must be underwent anticoagulation and correctly controlled by PT-INR. And if patients have no other risk factors, PICCS study confirmed that there was no difference of recurrence rate between anticoagulation and aspirin therapy.

We describe a 50-year-old woman with an incident of systemic and pulmonary embolism in whom transoesophageal examination (TEE) with the aid of contrast echocardiography (CE) identified a patent foramen ovale (PFO) with a residual thrombus between atrial septum and PFO valve suggesting paradoxical systemic embolization. The patient was diagnosed as heterozygous for prothrombin G20210A mutation. Control TEE performed after fibrinolysis, 2 months of heparin treatment followed by oral anticoagulation did not show any embolic material within the PFO.

Since it was first described in 1877, paradoxical embolism has become widely accepted as an etiology of stroke and peripheral vascular thrombotic occlusion. Less common are paradoxical emboli to the coronary artery. On the basis of limited pathologic and clinical series, it appears that paradoxical coronary emboli account for 5%-10% of all paradoxical emboli. Paradoxical coronary emboli have been described in all age groups, from neonates to the elderly, reflecting a wide spectrum of cardiac structural abnormality and clinical circumstance. Strategies for management should focus on treatment of acute coronary occlusion as well as prevention of future emboli.

Embolic events of the carotid bifurcatin are a rare cause of cerebrovascular accidents. We observed two patients who showed a spontaneous recanalisation of an embolic occlusion of the extracranial vessels when treated with conservative procedure using heparin. Both patients had a near complete remission of the symptoms without impairment in their daily activities.

Brain embolisms in younger persons are rare but are often caused by a paradoxical embolism, the embolic entry of a venous thrombus into the systemic circulation through a right-to-left shunt. A 27-year-old pregnant woman presented with hemiplegia that had been treated with an antiplatelet agent since the occurrence of a paradoxical brain embolism via the pulmonary arteriovenous fistula. A tendency of hypercoagulation is generally observed during pregnancy, so a patient with this condition has a strong risk factor for venous thromboembolism during pregnancy and even more so for arterial thromboembolism under the intense strain of labor, which is much stronger than that of the Valsalva maneuver. This case had been controlled well with an antiplatelet agent and an anticoagulant while the levels of coagulation and fibrinolytic factors were monitored and was followed by a successful pregnancy outcome.

Paradoxical embolism (PE) is an uncommonly diagnosed cause of unexplained ischemic cerebral event. Its diagnosis is based on established criteria and the failure to identify an arterial or cardiac embolic source. The association between patent foramen ovale (PFO) and cryptogenic stroke has repeatedly been demonstrated in clinical studies. Transesophageal contrast echocardiography is the best diagnostic test. Surgical or endovascular PFO closure is recommended for the long-term prevention of PE.