Paradoxical Thromboembolism: A Trip Better Left Untraveled

Abstract

Introduction

Pulmonary embolism is a common sequela of deep vein thrombosis (DVT). Less well documented is the occurrence of DVT and its relationship to stroke via an intracardiac shunt such as a patent foramen ovale (PFO). We report a case of DVT and stroke in conjunction to the presence of intracardiac thrombus and a moderate-sized PFO.

Methods

This is a case study report of a 61-year-old woman with a previous medical history of hyperlipidemia only who traveled to Mexico from the Unites States. The trip included three long bus trips of 12, 13, and 14 hours in duration. This patient presented to a hospital in Mexico with severe headache and right-sided weakness. The patient was diagnosed and treated for left hemispheric stroke and eventually transported to our hospital in Houston, Texas, for further stroke evaluation and management. With the use of a Philips IE33 8 MHz linear array probe and multi-plane TEE probe as well as a Siemens Sequoia 4V phased array probe, we were able to safely and accurately diagnose and manage the patient's condition until intervention could be safely performed.

Results

Multiple diagnostic imaging tests were performed, including a bilateral lower-extremity duplex venous ultrasound, duplex carotid ultrasound, transthoracic and transesophageal echocardiograms, as well as computed tomography scans of the chest and brain. With the patient's current condition and symptoms as well as the collected findings, our test results indicated that a paradoxical thromboembolic event had most likely occurred. There was right lower-extremity DVT, bilateral pulmonary embolisms, and large and highly mobile thrombus within the right-side chambers of the heart that occasionally protruded through a moderate size patent foramen ovale of 0.9 cm. The left distal common carotid artery and internal carotid artery were found to be occluded, and initial computed tomography scan of the brain showed a large left middle cerebral artery distribution infarct.

Conclusion

Venous thromboembolic disease can cause stroke in the presence of an intracardiac shunt such as a PFO. The use of vascular and cardiac ultrasound examinations is critical in determining the etiology of cerebrovascular events. We document a rare case of combined DVT, pulmonary embolism, intracardiac thrombus, PFO, and extracranial carotid arterial occlusion. Although the prevalence of DVT and intracardiac shunts alone is high, it is unclear from the literature which patients would benefit from PFO closure.