In patients with pulmonary embolism, patent foramen ovale (PFO) is associated with increased prevalence of silent brain infarcts (SBI). PFOs have been studied in patients with cryptogenic stroke with an increased likelihood of causing stroke in patients of less than 55 years. We present the case of a 56‐year‐old man who developed an acute stroke with neurological deficit after being diagnosed with pulmonary embolism (PE) and was found to be having a PFO. A 56‐year‐old white man with history of hypertension, hyperlipidemia and prosthetic knee joint was admitted with septic arthritis and underwent surgical removal of the prosthesis. Postoperatively he developed acute shortness of breath and tachycardia. CT angiogram of chest showed bilateral PE and lower‐extremity ultrasound was negative for clots. He was started on anticoagulation with heparin. On the following day, he complained of inability to move his left upper extremity. Physical examination showed 0/5 motor strength in the left upper extremity with preserved strength otherwise. Brain MRI showed an acute infarct in the right frontal lobe. A moderate‐sized PFO was found on trans‐esophageal echocardiography (TEE) with bubble study. He was conservatively managed for stroke with physical therapy. Anticoagulation for PE was continued. His shortness of breath and tachycardia resolved along with a significant improvement in left arm weakness.
The prevalence of brain infarct has been studied in the presence of PFO in patients having PE. In one study up to 33.3% of patients with PFO and PE were found to have SBI on MRI. In our patient, a clinically significant infarct occurred after PE. With the presence of PFO and absence of any other source of embolism, it can be presumed that the source of embolus was from PE. This is a very rare case in which both venous and arterial emboli are present together. There is always a concern about the use of anticoagulation in acute stroke and the increased risk of bleeding.
Our patient received full anticoagulation for PE without any bleeding. In fact, his neurological status improved significantly during his stay in the hospital. The outcome of patients in PE along with paradoxical arterial embolism (PDE) is unknown. Prospective patient registries would be helpful to determine both cardiopulmonary and neurological outcomes along with therapeutic interventions with anticoagulation and surgical closure of PFO.
To cite this abstract:Ramesh N, Koushik G, Soota K, Christidis E. Clot Begets a Clot: Pfo As a Gateway to Paradoxical Arterial Embolism. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 499. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/clot-begets-a-clot-pfo-as-a-gateway-to-paradoxical-arterial-embolism/. Accessed January 22, 2020.