A patient with multiple paradoxical emboli

Abstract

We present a case report of simultaneous pulmonary emboli and paradoxical embolism to the cerebellum causing a stroke and severe ischemia to the left leg. This patient had risk factors for thromboembolic events that included autoimmune disease, cancer, and recent pelvic surgery. The presence of a perforate foramen ovale was suspected on his initial presentation and confirmed with echocardiography. For acute leg ischemia, this patient underwent emergent left common femoral embolectomy. The potential benefit of immediate anticoagulation had to be weighed against the risk of hemorrhagic transformation of his cerebellar stroke with possible compression of the fourth ventricle. In the end, full anticoagulation was delayed with interval placement of a retrievable inferior vena cava filter. This case illustrates the challenges faced in treating a patient with multiple paradoxical emboli. (J Vasc Surg 2015;-:1-3.) CASE REPORTConsent was obtained from the patient to publish this case report along with the images. The patient is a 57-year-old man who presented to the emergency department with a 12-hour history of vertigo, nausea, left leg weakness, and shortness of breath at rest. He was unable to get out of bed as lifting his head off the pillow led to a sensation that "everything was spinning." He also complained of escalating pain followed by numbness and weakness in his left foot. In addition, his shortness of breath was unusual for him as he normally walked about a mile a day for exercise.Pertinent past medical history included Wegener granulomatosis, transitional cell bladder cancer, hypertension, and venous thromboembolism. He completed a 12-month course of systemic anticoagulation after a pulmonary embolus developed 5 years ago. At that time, the patient was evaluated for a possible hypercoagulable syndrome and none was found. The patient had undergone a radical cystoprostatectomy with neobladder creation for bladder cancer about 2 months before this current presentation.On physical examination, the patient was noted to have nystagmus with head movement. He had significant dysmetria. Speech was slurred but otherwise intact. There was no facial droop. His left lower extremity was white and insensate below the knee. There was minimal plantar flexion, and the left foot was paralyzed. There was no pulse in the left leg. A Doppler signal was present in the left femoral artery. Neurovascular examination findings of the right lower extremity were unremarkable.Pertinent diagnostic imaging included computed tomography (CT) of the head, showing an acute right cerebellar infarct (Fig 1); CT angiography of the chest, showing bilateral pulmonary emboli (Fig 2); and CT of the abdomen and pelvis (done as part of the workup for nausea), showing an acute cutoff at the left common femoral artery.At this point, the patient was diagnosed with a cerebellar stroke, pulmonary emboli, and critical ischemia of the left lower extremity. He was taken emergently to the operating room, where a left common femoral artery embolectomy was perform...

Simultaneous Pulmonary Embolism and Ischemic Stroke in a Patient with Cor Biloculare after Glenn Anastomosis

“…At present, there are no standard recommendations for anti-thrombotic therapy in patients with concomitant PE and embolic stroke [Bonnel 2015]. Management modalities including anticoagulation, thrombolytic therapy or endovascular embolectomy have been used alone or in combination previously [Gunta 2012;Omar 2013;Liu 2015]. In the immediate postoperative period, thrombolytic therapy and endovascular embolectomy were believed to be contraindicated.…”

Atypical manifestations of pulmonary embolism

“…However, in another study among 113 consecutive patients (mean age 62) with suspected cardiogenic embolic stroke and patent foramen ovale (PFO), CTPA identi ied only 4 patients with PE [91]. An analysis of 12 anecdotal reports of PE-related PDE [92][93][94][95][96][97][98][99][100][101][102][103][104][105] reveals three patterns of clinical presentation (Table 4), namely, simultaneous occurrence of typical PE symptoms(or hypoxaemia) and symptoms of PDE, occurrence of PE symptoms followed by occurrence of stroke a day or so later, and occurrence of stroke without any documentation of breathlessness. In the latter category were four patients [102][103][104][105] in whom PDE-related stroke occurred in a PE patient who had reported neither breathlessness, chest pain or cough.…”