Paradoxical embolism is a well-recognized cause of stroke. While the diagnosis in the majority of the cases with a patent foramen ovale is presumptive, numerous treatment strategies have been described. However, there is no single approach that has been overwhelmingly recom mended for these patients. A patient is described who presented with ischemic stroke. Transesophageal echocardiography revealed a thrombus that straddled a patent foramen ovale. Anticoagulation with intravenous heparin resulted in resolution of thrombus and neuro logic deficit. The literature regarding diagnosis and treatment of paradoxical embolism in the presence of patent foramen ovale is reviewed.
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References
1.
Connheim J.: Thrombose und Embolie. Vorlesung uber Allgemeine Pathologie. Berlin: Hirschwald, 1877, p 134.
2.
Loscalzo J.Paradoxical embolism: Clinical presentation, diagnostic strategies, and therapeutic options. Am Heart J112:141-145, 1986.
3.
Johnson BI: Paradoxical embolism. J Clin Pathol4:316-332, 1951.
4.
Leonard Rcf, Neville E., Hall Rjc: Paradoxical embolism—a review of cases diagnosed during life . Eur Heart J3:362-370, 1982.
5.
Meister SG, Grossman W., Dexter L., et al: Paradoxical embolism-diagnosed during life. Am J Med53:292-298, 1972.
6.
Bogousslavsky J., Cachin C., Regali F., et al, for the Lausanne Stroke Registry Group: Cardiac sources of embolism and cerebral infarction. Neurology41:855-959, 1991.
7.
Di Tullio, Sacco RL, Gopal A., et al: Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med117:461-465, 1992.
8.
Cabanes L., Mas JL, Cohen A., et al: Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age: A study using transesophageal echocardiography. Stroke24:1865-1873, 1993.
9.
Mas JL, Zuber M.: Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack: French Study Group on Patent Foramen Ovale an Atrial Septal Aneurysm . Am Heart J130:1083-1088, 1995 .
10.
Broderick J. , Brott T., Kothari R., et al: The Greater Cincinnati/Northern Kentucky Stroke Study. Preliminary first-ever and total incidence rates of stroke among blacks. Stroke29:415-421, 1998.
11.
Asinger RW, Dyken ML, Fisher M., et al: Cardiogenic brain embolism: The second report of the Cerebral Embolism Task Force. Arch Neurol46:727-743, 1989.
12.
Caplan LR, Heir DB, D'Cruz I: Cerebral embolism in the Michael Reese stroke registry. Stroke14:530-536, 1983.
13.
Sacco RL, Ellenberg JH, Mohr JP, et al: Infarcts of undetermined cause: The NINCDS stroke data bank . Ann Neurol25:382-390, 1989.
14.
Lechat P., Mas JL, Lascault G., et al: Prevalence of Patent foramen ovale in patients with stroke. New Engl J Med318:1148-1152, 1988 .
15.
Lynch JJ, Schuchard GH, Gross CM, et al: Prevalence of right-to-left atrial shunting in a healthy population: Detection by Valsalva maneuver contrast echocardiography. Am J Cardiol53:1478-1480, 1984.
Bridges ND, Hellenbrand W., Latson L., et al: Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation86:1902-1908, 1992.
18.
Hagen PT, Scholz DG, Edward WD: Incidence and size of patent foramen ovale during the first 10 decades of life: An autopsy study of 965 normal hearts. Mayo Clin Proc59:17-20, 1984.
19.
Hausmann D. , Mügge A., Daniel W.: Identification of patent foramen ovale permitting paradoxical embolism. J Am Coll Cardiol26:1030-1038, 1995.
20.
Homma S., Di Tullio MR, Sacco RL, et al: Character- istics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiography study. Stroke25:582-586, 1994.
21.
Schuchlenz HW , Weihs W., Horner S., et al: The association between the diameter of a patent foramen ovale and the risk of embolic cerebrovascular events. Am J Med109:456-462, 2000.
22.
DeCatro S., Cartoni D., Fiorelli M., et al: Morphological and functional characteristics of patent foramen ovale and their embolic implications. Stroke31:2407-2413, 2000.
23.
Higgins JR, Strunk BL, Schiller NB: Diagnosis of paradoxical embolism with contrast echocardiography. Am Heart J107:375-377, 1984.
24.
Reeder GS, Khandheria BK, Seward JB, et al: Transesophageal echocardiography and cardiac masses. Mayo Clin Proc66:1101-1109, 1991 .
25.
Nemec JJ, Marwick TH, Lorig RJ: Comparison of transcranial Doppler ultrasound and transesophageal contrast echocardiography in the detection of interatrial right-to-left shunts . Am J Cardiol68: 1498-1502, 1991 .
26.
Devuyst G., Bogousslavsky J., Ruchat P., et al: Prognosis after stroke followed by surgical closure of patent foramen ovale: A prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology47:1162-1166, 1996.
27.
Homma S., Di Tullio MR, Sacco RL, et al: Surgical closure of patent foramen ovale in cryptogenic stroke patients. Stroke28:2376-2381, 1997 .
28.
Dearani J., Ugurlu B., Danielson G., et al: Surgical patent foramen ovale for prevention of paradoxical embolism-related cerebrovascular events. Circulation100(suppl II):II-171-175, 1999.
29.
Windecker S. , Wahl A., Tushar C., et al: Percutaneous closure of patent foramen ovale in patients with paradoxical embolism. Long-term risk of recurrent thromboembolic events. Circulation101:893-898, 2000.
