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Acute limb ischemia (ALI) is the sudden onset of decreased blood supply to the extremities and carries a poor prognosis for the affected limb and survival. A rare but well-recognized embolic etiology is a paradoxical embolism, the translocation of a thrombus from venous to arterial circulation through an intracardiac communication, most commonly a patent foramen ovale. The presentation of ALI secondary to a PFO-mediated paradoxical embolism is most often accompanied by combinations of deep vein thrombosis (DVT), pulmonary embolism (PE), and an acute cerebral or visceral ischemia. We present the first documented case of a Rutherford class I ALI secondary to a PFO-mediated paradoxical embolism, ipsilateral DVT, and PE in a 29-year-old female who was surgically managed for her disabling claudication rather than limb salvage. The overlapping presentation of a viable ALI and ipsilateral DVT created a challenging clinical diagnosis. Our review of the literature on PFO-mediated paradoxical emboli involved 43 reports including 51 patients with various arterial thromboses; 19 of these cases involved lower extremity ALI. This case report is the first case to date that demonstrates a paradoxical embolism causing acute lower extremity ischemia with ipsilateral DVT and no additional limb/visceral ischemia to suggest the diagnosis of ALI. We also highlight the role that quality of life plays in vascular surgical decision-making, extending ALI management goals to not only reducing mortality and major amputations, but also improving quality of life. [ABSTRACT FROM AUTHOR]

Background and Objectives: Cancer is associated with an increased risk of acute ischemic stroke (AIS) and venous thromboembolism. The role of a cardiac right-to-left shunt (RLS) as a surrogate parameter for paradoxical embolism in cancer-related strokes is uncertain. We sought to investigate the relationship between the presence of an RLS and cancer in AIS patients. Methods: We included consecutive AIS patients hospitalized at our tertiary stroke center between January 2015 and December 2020 with available RLS status as detected on transesophageal echocardiography (TEE). Active cancers were retrospectively identified and the association with RLS was assessed with multivariable logistic regression and inverse probability of treatment weighting to minimize the ascertainment bias of having a TEE obtained. Results: Of the 2236 AIS patients included, 103 (4.6%) had active cancer, of whom 24 (23%) were diagnosed with RLS. An RLS was present in 774 out of the 2133 AIS patients without active cancer (36%). After adjustment and weighting, the absence of RLS was associated with active cancer (adjusted odds ratio (aOR) 2.29; 95% confidence interval (CI), 1.14–4.58). When analysis was restricted to patients younger than 60 years of age or those with a high-risk RLS (Risk of Paradoxical Embolism Score ⩾ 6), there was no association between RLS and cancer (aOR, 3.07; 95% CI, 0.79–11.88 and aOR, 0.56; 95% CI, 0.10–3.10, respectively). Conclusion: RLS was diagnosed less frequently in AIS patients with cancer than in cancer-free patients, suggesting that arterial sources may play a larger role in cancer-related strokes than paradoxical venous embolization. Future studies are needed to validate these findings and evaluate potential therapeutic implications, such as the general indication, or lack thereof, for patent foramen ovale (PFO) closure in this patient population. [ABSTRACT FROM AUTHOR]

Background: Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant inherited vascular disorder that can involve multiple organs, thus can be associated with so many clinical departments that proper screening and diagnosis of HHT are needed for providing better management of both patients and their family members. Case presentation: We present a 58-year-old female patient with recurrent paradoxical brain embolism due to HHT. She received aspirin therapy and underwent pulmonary arteriovenous malformation embolization, recovering well and discharged 3 days postoperatively. Though ischemic stroke caused by HHT-induced vascular disorders has been reported, our patient presented with both recurrent paradoxical brain embolisms and radiologic findings of bilateral globus pallidus manganese deposition at the same time, a combination rarely reported. We also review the literature on the clinical features and management of HHT for prompt diagnosis of this genetic disease behind paradoxical embolism. Conclusions: When patients with ischemic stroke, especially recurrent ischemic stroke, have combined arteriovenous malformations (AVMs) in single or multiple organs, or clues for AVMs like manganese deposition in globus pallidus, genetic diseases such as HHT may be the reason for ischemic stroke and shouldn't be missed in the evaluation of embolic sources. [ABSTRACT FROM AUTHOR]

Background and Aims: Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the treatment of several complications of portal hypertension (PH), including non‐neoplastic portal vein thrombosis (PVT). Selection criteria for TIPS in PVT are not yet well established. Despite anecdotal, cases of thromboembolic events from paradoxical embolism due to the presence of patent foramen ovale (PFO) after TIPS placement have been reported in the literature. Therefore, we aimed at describing our experience in patients with non‐neoplastic splanchnic vein thrombosis (SVT) who underwent TIPS following PFO screening. Methods: We conducted a single‐centre retrospective study, including consecutive patients who underwent TIPS for the complications of cirrhotic and non‐cirrhotic portal hypertension (NCPH) and having SVT. Results: Of 100 TIPS placed in patients with SVT, 85 patients were screened for PFO by bubble‐contrast transthoracic echocardiography (TTE) with PFO being detected in 22 (26%) cases. PFO was more frequently detected in patients with non‐cirrhotic portal hypertension (NCPH) (23% in the PFO group vs. 6% in those without PFO, p =.04) and cavernomatosis (46% in the PFO group vs. 19% in those without PFO, p =.008). Percutaneous closure was effectively performed in 11 (50%) after multidisciplinary evaluation of anatomical and clinical features. No major complications were observed following closure. Conclusions: PFO screening and treatment may be considered feasible for patients with SVT who undergo TIPS placement. [ABSTRACT FROM AUTHOR]

Copyright of Family Medicine Forum / Forum Medycyny Rodzinnej is the property of VM Medica-VM Group (Via Medica) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background Residual interatrial shunt following percutaneous patent foramen ovale (PFO) closure is a rare complication that can be associated with persistent migraine. Case summary A 32-year-old woman with a history of percutaneous PFO closure due to a previous coronary paradoxical embolism and a condition of drug-refractory migraine underwent transoesophageal echocardiography (TOE) to investigate further recurrent migraine attacks. A partial displacement of a PFO occluder device was found, and it was successfully treated through the fluoroscopic and TOE-guided positioning of a second occluder in overlap with the previous one. The patient reported no more migraine attacks at the 6-month follow-up visit. Discussion Residual interatrial shunt should be suspected in patients with persistent migraine and a history of percutaneous PFO closure. Fluoroscopic and TOE-guided closure of residual interatrial shunt with a second PFO occlude device seems to be a safe and clinically effective strategy to manage persistent migraine. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Decompression sickness (DCS) is a medical condition caused by outgassing of dissolved nitrogen following rapid ascent by divers and aviators. Cutaneous DCS, historically termed cutis marmorata (CM), presents as a predominantly truncal reticular violaceous-to-dusky eruption. The prevailing theories for its pathogenesis include: localized cutaneous outgassing, paradoxical embolism across a right-to-left shunt (RLS), and brainstem emboli disrupting autonomic control of cutaneous microcirculation. METHODS: We conducted a systematic review of reports of cutaneous DCS to investigate relationships among CM, RLS, and neurological sequelae to better elucidate the mechanism of CM. A literature search examining reports of cutaneous DCS yielded 31 eligible studies, comprising a pooled total of 128 patients. RESULTS: Of the patients with documented workup, 84% showed evidence of RLS with CM. Subsequently 18 patients underwent percutaneous closure of intracardiac RLS with no recurrence of DCS. Of the patients with documented neurological evaluations, 57% experienced both CM and neurological DCS manifestations. The coexistence of RLS and neurological symptoms with CM was noted in numerous cases; exact percentages of overlap cannot be stated due to data unavailability. DISCUSSION: Our results indicating the striking coexistence of RLS and neurological sequelae in CM patients is supportive of the paradoxical embolism theory of pathogenesis. The frequent coincidence of CM with RLS and neurological symptoms raises concern that CM may signify vulnerability to devastating systemic gas emboli. CM has historically been considered trivial and self-limiting; however, our results support reappraisal of its clinical significance and potential reclassification to the more severe subtype. [ABSTRACT FROM AUTHOR]

BACKGROUND: Migraine is a chronic neurovascular disease with high incidence rate and medical-social significance. Despite more than half a century of studying the disease, the pathogenesis of migraine is not yet completely clear. The results of separate research works demonstrate the inter-relation of migraine with the presence of patent foramen ovale and circulation shunting from the right side to the left one. AIM: Detailing the incidence rates and the clinical characteristics of migraine, as well as the effects of endovascular installation of the occluding device into the patent foramen ovale in terms of migraine course in a cohort of patients that had an ischemic stroke episode according to the mechanism of paradoxical embolism due to having a functionally significant patent foramen ovale. METHODS: The examined population included 97 patients aged from 18 to 50 years old (mean age 32.29±2.19 years; 70.8% females), undergoing examination procedures at the Research Center of Neurology from January 2018 until October 2023. All the patients previously had an ischemic stroke that had involved the mechanism of paradoxical embolism, associated with the presence of patent foramen ovale and high functional significance shunting. All the patients underwent an assessment of their conditions associated with the presence of a patent foramen ovale — migraine with or without aura, other procedures included the detailing of headache characteristics and of the effects of migraine on social adaptation. The endovascular intervention was performed in 61 patients. Dynamic follow-up data were obtained for 36 patients, of which 24 migraine patients had an assessment of headache characteristics before and after the foramen ovale closure. RESULTS: Within the cohort of patients with patent foramen ovale accompanied with functionally significant shunting and with a previous episode of ischemic stroke, the incidence of migraine was 39.2% (no aura — 21 patients or 55%; with aura — 17, or 45%), while the proportions of women and men being 1.9:1. The rate of headache attacks was 4 [1; 7] days per month. In 6 months after the installation of the foramen ovale occluder, migraine patients were showing a significant decrease in the rate of headache onsets from 4 [2; 24] to 2 [1; 5] days a month (р=0.009); a decrease was reported for pain intensity from 7 [7; 9] to 3 [3; 7] points of the visual analogue scale for pain (р=0.0001) along with a decrease in the degree of migraine affecting the patients’ everyday activity from 20 [6; 89] to 17 [2; 26] points (р=0.019) of the MIDAS questionnaire. CONCLUSION: The present research has confirmed the high incidence found in a cohort of patients with patent foramen ovale. Installation of the occluder resulted in a decrease in the rate and intensity of headache along with a decrease of migraine affecting the social adaptation. The research limitations were a small number of patients and the absence of data on the residual shunting circulation.

BACKGROUND: Pulmonary arteriovenous malformations (PAVMs) can cause acute ischemic strokes (AISs) through paradoxical embolism. The clinical and imaging features of AIS due to PAVMs have not been studied. We report a case and perform a systematic review of the clinical and imaging characteristics of patients with AIS due to PAVMs. This may provide clues to screen patients with AIS for PAVMs and treat them appropriately to prevent further strokes. MATERIALS AND METHODS: MEDLINE, EMBASE, and Web of Science databases were searched from inception to October 2023. We included patients of any age with AIS attributed to PAVM. Studies without clinical data were excluded. Demographics, AIS characteristics (location and arterial territories), and PAVM characteristics (location, size, and treatment) were recorded. RESULTS: A 47-year-old female presented with acute vertigo and gait imbalance. Magnetic resonance imaging showed AIS in the right cerebellum. CT chest confirmed a PAVM in the right lower lobe. Endovascular coil closure was performed. We identified 102 patients from 96 records. The mean age was 47.4 ± 17 years (67% female). Seventy percent had single AIS and 30% had multiple. The location was anterior circulation in 50%, posterior in 37%, and both in 13%. The most common arterial territory was middle-cerebral (51%), followed by posterior-cerebral (25%). PAVMs were mostly single (78%) and in the lower lobes (66%). Thirty-three had hereditary hemorrhagic telangiectasia (HHT) (33%). CONCLUSIONS: PAVM-related strokes occur at a young age and may have a high propensity for multifocality and posterior circulation location. Patients with PAVMs and AIS should be screened for HHT and venous thromboses.

Abstract Background Although rare, paradoxical embolism sometimes occurs with patent ductus arteriosus (PDA). This study presents a case of PDA-associated paradoxical embolism with acute ischemic stroke (AIS) and pulmonary embolism (PE) following thoracoscopic surgery. Case Presentation A 65-year-old woman developed acute-onset aphasia and right hemiparesis on the third day following thoracoscopic resection for a right lung tumor. Brain magnetic resonance imaging revealed multiple infarcts, and lower extremity venous Doppler ultrasound revealed deep vein thrombosis. The patient subsequently developed dyspnea, tachycardia, and hypoxemia. PE was confirmed by percutaneous transfemoral venous selective pulmonary angiography, which meanwhile demonstrated a PDA lesion. The patient, after receiving catheter-directed thrombolysis and inferior vena cava filter placement, improved in both neurological and respiratory status. Conclusion For an uncommon but potentially fatal case with PDA-induced paradoxical embolism causing AIS and PE, early recognition and treatment are vital. Further studies are warranted to determine the optimal management and prognosis of patients with PDA-related embolic events.

Background. Pulmonary embolism (PE) is a common and potentially life-threatening diagnosis when a certain amount of thrombotic mass obstructs blood flow through the pulmonary circulation. The finding of acute and subacute ischaemic foci on magnetic resonance imaging (MRI) of the brain in a group of patients with this diagnosis in whom we demonstrate the presence of patent foramen ovale (PFO) by transoesophageal echocardiography (TEE) is surprisingly high. Methods. A total of 129 patients with a diagnosis of pulmonary embolism (confirmed by computed tomography with contrast agent, CTA) who consented to further examination were examined by transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) with contrast agent, underwent magnetic resonance imaging of the brain according to a specific protocol, and underwent a comprehensive baseline laboratory examination. Results. In our group of 129 patients, we found the presence of PFO in 36.4% (n=47) of them. A total of 5.4% (n=7) patients had asymptomatic acute and subacute ischaemic changes on brain MRI; 6 of them had concomitant PFO. The statistically significant correlation between troponin levels and the presence of pathological findings on MRI and the trend of a similar correlation for NT-proBNP values is also very interesting finding. Conclusions. The association between the presence of PFO and the occurrence of symptomatic or asymptomatic findings on brain MRI is a well-known fact (the issue of paradoxical embolism) but the high frequency of acute and subacute lesions on brain MRI in the group of patients with a diagnosis of acute PE is surprising.

Isolated paresis of the inferior rectus muscle (IRM) represents a rare occurrence. This case report involves a young adult male who, abruptly during a Valsalva maneuver, encountered acute vertical diplopia due to right IRM paresis, resolving spontaneously within a few hours. The patient presented without identifiable risk factors, and magnetic resonance imaging revealed a minor left thalamic ischemic lesion. A cardiac study identified the presence of a patent foramen ovale, potentially associated with a paradoxical embolism, indicating its likely role in this transient ischemic event. [ABSTRACT FROM AUTHOR]

A 67‐year‐old woman with pulmonary hypertension (PH) presented with a 1‐day history of worsening shortness of breath and pleuritic chest pain and was found to have a troponin T level of 3755 ng/L (ref. range 0–19 ng/L). An initial diagnostic workup in the emergency department (ED) led to an urgent left heart catheterization which revealed a 90% occlusive right coronary artery blood clot, even though a recent heart catheterization less than a month prior was completely unremarkable. Further workup led to the discovery of a patent foramen ovale (PFO) and an aneurysmal interatrial septum, suggesting the presence of a paradoxical embolism. While typically asymptomatic, a PFO is an important clinical entity that can lead to irreversible cardiac damage. Suspicion should be high for this finding in the case of an acute myocardial infarction (MI) with no clear cause, especially in a patient with elevated right heart pressures. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Cesarean scar pregnancy cases who undergo hysteroscopic suction aspiration could be at higher risk of air emboli due to dilated, low‐resistant, high‐velocity blood vessels. [ABSTRACT FROM AUTHOR]

Background Myocardial infarction (MI) caused by patent foramen ovale (PFO)-based paradoxical embolism is rare, and there are few case reports in the literature. Case summary Here, we report a case of MI in which optical coherence tomography revealed in situ thrombi in the PFO channel. Discussion In addition to paradoxical embolism, in situ thrombus may also be one of the pathogenic mechanisms of PFO in patients with MI. [ABSTRACT FROM AUTHOR]

Background: Although rare, paradoxical embolism sometimes occurs with patent ductus arteriosus (PDA). This study presents a case of PDA-associated paradoxical embolism with acute ischemic stroke (AIS) and pulmonary embolism (PE) following thoracoscopic surgery. Case Presentation: A 65-year-old woman developed acute-onset aphasia and right hemiparesis on the third day following thoracoscopic resection for a right lung tumor. Brain magnetic resonance imaging revealed multiple infarcts, and lower extremity venous Doppler ultrasound revealed deep vein thrombosis. The patient subsequently developed dyspnea, tachycardia, and hypoxemia. PE was confirmed by percutaneous transfemoral venous selective pulmonary angiography, which meanwhile demonstrated a PDA lesion. The patient, after receiving catheter-directed thrombolysis and inferior vena cava filter placement, improved in both neurological and respiratory status. Conclusion: For an uncommon but potentially fatal case with PDA-induced paradoxical embolism causing AIS and PE, early recognition and treatment are vital. Further studies are warranted to determine the optimal management and prognosis of patients with PDA-related embolic events. [ABSTRACT FROM AUTHOR]

At present, the patent foramen ovale (PFO) does not receive the deserved medical attention. The PFO poses a serious threat to health and even the life of mankind. The first respective case report in the medical literature dates back to the 19th century. It led to death. The fact that a PFO is present in roughly 25% of people underscores its overall potential to cause harm. Yet at the same time, the sheer number discourages the medical community from screening for it and from treating it. About 5% of the population have particularly dangerous forms of PFOs. Such PFOs portray a high enough risk for clinical events, the likes of death, stroke, myocardial infarction, or ocular, visceral, and peripheral embolism, to justify screening for them. Highly significant health incidents being at stake, it appears obvious that PFO closure should be used for primary prevention. This is supported by the fact that closing a PFO is the simplest intervention in cardiology, with presumably the highest clinical yield. Being mainly a preventive measure, PFO closure represents a mechanical vaccination. When closing PFOs for one of the rarer therapeutic indications (migraine, platypnea orthodeoxia, etc.), patients automatically profit from the collateral benefit of getting, at the same time, mechanically vaccinated for life against paradoxical embolism. Vice versa, closing a PFO for the prevention of paradoxical embolism betters or cures migraine or exercise dyspnea not infrequently, thereby improving quality of life as a collateral benefit. [ABSTRACT FROM AUTHOR]

Background. Pulmonary embolism (PE) is a common and potentially life-threatening diagnosis when a certain amount of thrombotic mass obstructs blood flow through the pulmonary circulation. The finding of acute and subacute ischaemic foci on magnetic resonance imaging (MRI) of the brain in a group of patients with this diagnosis in whom we demonstrate the presence of patent foramen ovale (PFO) by transoesophageal echocardiography (TEE) is surprisingly high. Methods. A total of 129 patients with a diagnosis of pulmonary embolism (confirmed by computed tomography with contrast agent, CTA) who consented to further examination were examined by transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) with contrast agent, underwent magnetic resonance imaging of the brain according to a specific protocol, and underwent a comprehensive baseline laboratory examination. Results. In our group of 129 patients, we found the presence of PFO in 36.4% (n=47) of them. A total of 5.4% (n=7) patients had asymptomatic acute and subacute ischaemic changes on brain MRI; 6 of them had concomitant PFO. The statistically significant correlation between troponin levels and the presence of pathological findings on MRI and the trend of a similar correlation for NT-proBNP values is also very interesting finding. Conclusions. The association between the presence of PFO and the occurrence of symptomatic or asymptomatic findings on brain MRI is a well-known fact (the issue of paradoxical embolism) but the high frequency of acute and subacute lesions on brain MRI in the group of patients with a diagnosis of acute PE is surprising. [ABSTRACT FROM AUTHOR]

Background: perioperative stroke is one of the major complications after surgery. Patent foramen ovale (PFO) increases the risk of stroke in non-cardiac surgery by right-to-left shunt related to intraoperative hemodynamic alterations, leading to paradoxical embolism. Transesophageal echocardiography is the best tool for obtaining anatomical confirmation of PFO and essential details such as the PFO measure and the degree and direction of the shunt. Despite this, preoperative PFO screening is not routinely performed. Methods and results: we described the features of ten consecutive patients undergoing major abdominal surgery at the Abdominal Organ Transplant Intensive Care Unit, IRCCS Sant'Orsola, Bologna, Italy, who were screened for PFO using a PFO diagnostic and monitoring standardized intraoperative protocol by transesophageal echocardiography and transcranial color Doppler ultrasound. Finally, we highlighted the neurological and respiratory outcomes, the course and the management of three patients with intracardiac and extracardiac shunts. Conclusions: identifying an unknown PFO by a TCCD-TEE approach allowed the intraoperative monitoring of the shunt direction. It prevents the risk of complications secondary to paradoxical embolism in non-cardiac high-embolic-risk surgery. [ABSTRACT FROM AUTHOR]

Purpose: To develop an imaging prediction model for patients with embolic stroke of undetermined source (ESUS), we investigated the association of topographic diffusion-weighted imaging (DWI) patterns with potential embolic sources (PES) identified by transesophageal echocardiography. Methods: From a total of 992 consecutive patients with embolic stroke, 366 patients with the ESUS group were selected. ESUS was defined as no atrial fibrillation (Af) within 24h from admission and no PES after general examination. Clinical variables include age (> 80years, 70–80 years), sex, vascular risk factors and left atrial diameter > 4 cm. Age, sex and vascular risk factors adjusted odds ratio of each DWI for the different PESs were calculated. DWI was determined based on the arterial territories. Middle cerebral arteries were divided into 4 segments, i.e., M1–M4. Moreover, M2 segments were subdivided into superior and inferior branches. Results: The 366 patients consisted of 168 with paroxysmal Af (pAf), 77 with paradoxical embolism, 71 with aortic embolism and 50 with undetermined embolism after transesophageal echocardiography. The variables adjusted odds ratio (OR) of internal carotid artery (OR: 12.1, p = 0.037), M1 (4.2, p = 0.001), inferior M2 (7.5, p = 0.0041) and multiple cortical branches (12.6, p < 0.0001) were significantly higher in patients with pAf. Striatocapsular infarction (12.5, p < 0.0001) and posterior inferior cerebellar artery infarcts (3.6, p = 0.018) were significantly associated with paradoxical embolism. Clinical variables adjusted OR of multiple small scattered infarcts (8.3, p < 0.0001) were significantly higher in patients with aortic embolism. Conclusion: The associations of DWI with different PES have their distinctive characteristics and DWI along with clinical variables may help predict PES in patients with ESUS. [ABSTRACT FROM AUTHOR]

A paradoxical embolism is defined as a venous thrombus that crosses through a heart defect, into the systemic circulation, usually through a patent foramen ovale. Treatment varies between closure of patent foramen ovale vs. medical management based on a variety of individual risk factors and the cardiac defect's characteristics. We describe a case of paradoxical stroke complicated by hemorrhagic conversion, ultimately requiring an IVC filter.

Background: While cerebral infarction in children is rare, its prognosis is poor, and this condition can seriously burden society and families. A correlation between patent foramen ovale (PFO) and ischemic stroke has not been found in pediatric patients. Case presentation: We report a 7-year-old boy who suffered from multiple cerebral infarctions. Subsequently, the patient was diagnosed with an abnormal shunt of PFO. He underwent PFO closure and was followed up for 1 year. The patient did not experience any further cerebral infarction. Conclusions: With this case report, we want to illustrate that although the incidence rate of ischemic cerebral infarction in adolescents is very low, we should not neglect the role of PFO. Therefore, after exclusion other causes of cerebral infarction, PFO should be considered in adolescent and adult stroke patients with adult closure criteria in the same way. [ABSTRACT FROM AUTHOR]

Paradoxical embolism is a medical condition characterized by the migration of an embolus from a venous source into the systemic circulation. This occurs through a specific cardiac abnormality known as a right-to-left shunt, ultimately resulting in the possibility of arterial embolism. Patent foramen ovale (PFO) is the most common cause of intracardiac shunting. We reported a rare case of a 56-year-old man on hemodialysis with PFO and arteriovenous fistula dysfunction who suffered a paradoxical embolic ischemic stroke after percutaneous transluminal angioplasty. This case emphasized the potential risk of paradoxical embolism in hemodialysis patients with vascular access problems. We aimed to highlight the importance of searching for PFO, as it may serve as a possible source of embolism in these patients. [ABSTRACT FROM AUTHOR]

Introduction. Paradoxical embolism is a thrombotic event originating in the venous circulation, which manifests as arterial embolism through an anatomical cardiac or pulmonary defect. It is mainly associated with stroke, also presenting as acute myocardial infarction, renal infarction, and other ischemic events. Clinical case. A 47-year-old patient was admitted due to abdominal pain, which required emergency surgical management, finding significant intestinal ischemia. Additional studies found protein S deficiency and evidence of a patent foramen ovale. Discussion. Arterial thrombosis is known as unusual thrombosis; this situation requires to rule out associated thrombophilia or other prothrombotic diseases. Protein S deficiency is a rare thrombophilia, which in adults causes venous thrombosis. In the presence of anatomical defects, such as a patent foramen ovale, it can progress to arterial embolism, presenting a picture of paradoxical embolism. The study work of these patients requires imaging that demonstrates the aforementioned defect, as well as the possible origin of the emboli. Management is based on full anticoagulation, treatment of existing thrombotic manifestations, and management of the anatomical defect. Conclusions. Paradoxical embolism should be suspected in case of unusual thrombosis. It requires exhaustive studies based on imaging, and management should consist of anticoagulation and closure of the defect. [ABSTRACT FROM AUTHOR]

Copyright of Bosphorus Medical Journal / Boğaziçi Tıp Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: Unusual clinical course Background: A paradoxical air embolism (PAE) occurs when air entering the central venous circulation reaches the systemic circulation, occurring through an intracardiac shunt or intrapulmonary shunting. Patients presenting for liver transplantation often have intrapulmonary shunting due to pulmonary arterial vasodilation, even in the absence of hepatopulmonary syndrome. Here, we present a case of hemodynamic collapse believed to be caused by a PAE, which was diagnosed intraoperatively with transesophageal echocardiography (TEE). Case Report: A 60-year-old man who was diagnosed with non-alcoholic steatohepatitis cirrhosis presented for deceased donor orthotopic liver transplantation with utilization of normothermic machine perfusion. Following reperfusion of the liver allograft, TEE detected intrapulmonary shunting resulting in air within the left atrium, left ventricle, and ascending aorta. The patient developed severe biventricular dysfunction with ST-segment changes on electrocardiography monitoring and became acutely hypotensive with significant hepatic congestion 5 min after liver reperfusion. High doses of inotropic and vasopressor support were used as well as inhaled nitric oxide. The patient recovered after 30 min of medical management. The liver transplantation operation was successfully completed and the patient was discharged home on postoperative day 7. Conclusions: Intracardiac air at the time of reperfusion during liver transplantation can originate from the donor allograft and result in PAE in the setting of intrapulmonary shunting. PAE can result in intracoronary air and should be considered in cases of hemodynamic instability in liver transplantation, especially if air is seen within the left atrium, left ventricle, and ascending aorta. [ABSTRACT FROM AUTHOR]

Acute limb ischemia, or ALI, is a rapid decrease in limb perfusion due to an occlusion of an artery or a bypass graft. Most cases result from in situ thrombosis or embolism in patients with antecedent peripheral arterial disease. Potential sources of arterial embolism as a cause of this condition include cardiogenic, aortic, peripheral aneurysms with an associated mural thrombus or, less commonly, a paradoxical embolism through a septal defect. We present a rare case of ALI due to an underlying patent foramen ovale that was successfully treated following revascularization. This article emphasizes one of the more unusual mechanisms of ALI. Despite the rarity, physicians should maintain a high index of clinical suspicion for a paradoxical embolism across a patent foramen ovale in unexplained arterial occlusion. Correct mechanism identification ensures adequate referral and prompt treatment that may reduce complications. [ABSTRACT FROM AUTHOR]

Background Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Case summary A 64-year-old man presented to hospital with acute chest pain, shortness of breath, and pulmonary oedema. Electrocardiogram revealed ST-elevation myocardial infarction. D-dimer was 18.8 mg/L fibrinogen equivalent units (FEU) (normal <0.64), and troponin was 25 (normal 5–14 ng/L). After systemic thrombolysis, respiratory failure persisted, and the arterial blood gas showed PaO2 of 6.0 kPa (normal 10.5–13.5 kPa), with 100% oxygen delivery via high-flow nasal cannula. A computed tomography diagnosed bilateral lobar PE, and coronary angiogram showed multiple thrombus in the right coronary artery. A bubble study with thoracic echocardiogram revealed a large right–left inter-atrial shunt. The patient denied treatment with extracorporeal membrane oxygenation and surgical thrombectomy. With no access to percutaneous catheter-directed thrombectomy, the patient received three separate thrombolysis treatments followed by a continued infusion for 22 h. After 6 weeks in hospital, the patient was discharged to rehab. Discussion For a long time, PE has been largely seen as a medical disease. Intra-cardiac shunts such as patent foramen ovale can complicate thrombo-venous disease and introduce paradoxical shunts leading to arterial emboli and persistent hypoxaemia. Over recent years, modern percutaneous catheter-directed thrombectomy has been developed for both high-risk and intermediate to high-risk PEs. Thrombectomy might improve right ventricular function and haemodynamics, but there is lacking evidence from randomized trials on efficacy, safety, and long-term outcome. [ABSTRACT FROM AUTHOR]

Background: Paradoxical embolism is a rare cause of acute arterial occlusion. This phenomenon arises when embolic material travels from the venous system crosses an abnormal shunt such as patent foramen ovale, atrial septal defects, ventricular septal defects, or pulmonary arteriovenous malformations, into the arterial system. Impending paradoxical embolism refers to the presence of an entrapped thrombus in the patent foramen ovale. Case presentation: We report a case of a 68-year-old female patient who presented with an impending paradoxical embolism, alongside both concomitant pulmonary embolism and myocardial infarction with ST-segment elevation. Swiftly addressed through emergency cardiac surgery and systemic anticoagulation, the patient's condition was effectively treated. Conclusions: While the ideal treatment strategy for impending paradoxical embolism remains a topic of debate due to limited and inconclusive evidence, emergent open surgery should be contemplated in patients as it signifies a critical clinical emergency. [ABSTRACT FROM AUTHOR]

Impending paradoxical embolism (IPDE) is a right heart thrombus (RHT), in times of elevated pulmonary arterial pressure, that is trapped in a patent foramen ovale (PFO) Myers et al. (2010) (3). We present a case that highlights our multidisciplinary approach in a patient with IPDE with cardiogenic shock from pulmonary embolism (PE). • Diagnosis of paradoxical embolism (PDE) before advancements in imaging was made presumptively as it was impossible to visualize a clot as it traverses a cardiac defect. With the advent of echocardiography, it is now possible to visualize right heart thrombus (RHT) in vivo and see as it traverses a cardiac defect. This phenomenon is known as an impending paradoxical embolism (IPDE) • IPDE, must be acted promptly as it can embolize systemically. Literature regarding IPDE is scant but shows that surgical intervention is superior to systemic thrombolysis. However, percutaneous interventions have not been studied. • The patient was unable to undergo systemic thrombolysis or surgical intervention because of patient's history of Moyamoya, which proved too great a risk. Thus, a percutaneous approach involving interventional radiology (IR) and structural cardiology was employed. • Patient was initiated on venoarterial extracorporeal membrane oxygenation, a cardioembolic protection device was placed, and the IPDE was aspirated via an Angiovac. Once aspirated, the cardiac defect was occluded percutaneously. Aspiration thrombectomy of the massive pulmonary embolisms was then completed by IR. • As it stands now, the literature regarding which approach is superior is lacking. With advancements in echocardiography, more and more IPDE will be discovered. It is imperative to delineate whether a surgical, percutaneous, or systemic thrombolysis approach should be utilized. Further research should be undertaken. [ABSTRACT FROM AUTHOR]

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Air embolism (AE) is a subtype of embolism, caused by the entry of air into the vascular system. It is a predominantly iatrogenic complication, and its symptomatic form is severe, although uncommon. In some cases, a venous thrombi may pass into the arterial system through a venous-arterial shunt, characterizing a paradoxical embolism. Here, we describe the case of a previously healthy 44-year-old female who underwent cauda equina decompression and lumbar epidural abscess drainage. The patient suffered a paradoxical AE intraoperatively and died after 4 days. The occurrence of AE in lumbar spine surgeries in the prone position is rare, but the surgical team must be attentive to its clinical signs and quickly institute initial management when necessary.

Clarification of the aetiology of ischemic stroke (IS) in young adults (aged between 18 and 45 years) is an extremely difficult task, as rare causes that are hardly known to neurologists are very common. One of these causes is paradoxical embolism due to pulmonary arteriovenous malformation (AVM), one of the manifestations of hereditary hemorrhagic telangiectasia (HHT). The diagnosis of HHT-associated pulmonary AVMs and IS is a multistep task that requires a personalized multidisciplinary approach using high-tech ultrasound, tomographic and genetic examination methods. This article discusses the clinical case of a young patient with HHT and recurrent IS through the mechanism of paradoxical embolism from pulmonary AVMs; issues of diagnosis, treatment and prevention of both the underlying disease and recurrent vascular events are discussed.

The article discusses the complexity of the relationship between patent foramen oval (PFO) and embolic stroke of undetermined source (ESUS) in cryptogenic stroke patients. It emphasizes the challenges in risk stratification and treatment decisions, especially in distinguishing between ESUS and migraine patients with PFO, highlighting the need for more refined risk stratification tools for tailored treatment.

Background: This single‐center observational study aimed to compare the echocardiographic and clinical features in patients diagnosed with migraine and embolic stroke of undetermined source (ESUS) who presented with a known patent foramen ovale (PFO). Methods: Two‐dimensional and color Doppler images were obtained using various transthoracic echocardiography views for both migraine and ESUS patients. Suspected PFO cases underwent further assessment through contrast echocardiography and transesophageal echocardiography (TEE). High‐risk PFO characteristics were evaluated using TEE, and the Risk of Paradoxical Embolism (RoPe) score was calculated. Results: The study included 310 participants (age range: 18–60, 73.2% female), with 43.5% diagnosed with migraine and 56.5% with ESUS. Common comorbidities included diabetes (26.1%). High‐velocity shunting through the interatrial septum was observed in 35.5% of patients. ESUS patients were older, with higher rates of diabetes and hypertension, while active smoking was more prevalent among migraine patients. Basic echocardiographic parameters were mostly similar, except for elevated pulmonary artery systolic pressure in ESUS. ESUS patients exhibited a greater occurrence of large microbubble passage through the interatrial septum and longer PFO lengths compared to migraine patients. However, the RoPe and High‐risk PFO scores were similar between the groups. Conclusions: ESUS patients, characterized by older age and higher rates of diabetes and hypertension, demonstrated increased pulmonary artery pressure, more significant microbubble crossings, and longer PFO lengths. Conversely, migraine patients had a higher prevalence of active smoking. Despite differing clinical profiles, the risk scores for PFO‐related embolic events were comparable between the groups. These findings underscore potential distinctions between ESUS and migraine patients with PFO and their implications for management strategies. [ABSTRACT FROM AUTHOR]

Acute limb ischemia (ALI) is a large contributor to morbidity and mortality annually and can be managed either operatively or medically. ALI is most often caused by arterial embolism or in situ thrombosis and treatment is often dependent upon the severity. Anticoagulation is considered standard of care and first line therapy. However, more severe cases of ALI require surgical intervention. Paradoxical emboli are a rare and potentially under-appreciated cause of ALI. They arise when venous emboli, from a variety of sources, traverse a patent foramen ovale (PFO) to enter the arterial system, compromising blood flow to the affected end organ. In most cases, they can only be proven if the thrombus is identified as it crosses the cardiac defect, at which point it is an indication for surgery requiring PFO closure, management for the ischemia itself, and possible intervention for the embolism. In this report, we identify and discuss management of a series of cases where ALI was precipitated by PFOs that were discovered in the context of a pulmonary emboli that developed into paradoxical emboli. All patients had a confirmed diagnosis of COVID-19 which has been associated with a state of hypercoagulability and subsequent thrombus formation. [ABSTRACT FROM AUTHOR]

Copyright of Acta Médica Peruana is the property of Colegio Medico del Peru and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

We present a case of a patient with a transient ischaemic attack (TIA) likely due to paradoxical embolism through a patent foramen ovale (PFO). Her medical history included 2nd-degree heart block Mobitz II, which manifested with recurrent syncopes and was treated with a dual chamber pacemaker. During the interventional PFO closure procedure, we noted entrapment of the atrial pacemaker lead between the right-sided occluder disc and the interatrial septum. We were able to successfully move the lead aside using a 24 mm sizing balloon and subsequently developed the right-sided occluder disc in the correct position. In conclusion, pacemaker-lead entrapment between a PFO occluder disc and the interatrial septum can be prevented using a sizing balloon. [ABSTRACT FROM AUTHOR]

An unusual case of ischemic stroke due to calcified cerebral embolus occurring in a pregnant patient during the peripartum period is reported. The source of the embolus was suspected to be a pelvic phlebolith in origin which paradoxically embolized via a patent foramen ovale to the supraclinoid right internal carotid artery. To our knowledge, this is the first reported case of calcified cerebral embolus attributed to paradoxical embolism of a pelvic phlebolith, and we theorize that introduction of the phlebolith into the venous system may have occurred as a consequence of vascular remodeling due to pregnancy-related hemodynamic changes. Clinicians should be aware of this potential source of calcified cerebral emboli in patients with a patent foramen ovale during pregnancy. Our patient ultimately achieved an excellent outcome with surgical endarterectomy and embolectomy following an unsuccessful attempt at mechanical thrombectomy. [ABSTRACT FROM AUTHOR]

Chiari network is a embryogenic remmant of sinus venosus. This network tissue regresses during later growth leaving remnants in the right atrium. Chiari network does not regress completely and remnants remain in the right atrium in 2% of population. Remnants of Chiari-network are frequently confused with thrombus and vegetation on echocardiographic examinations. Chiari network is usually associated with interatrial septal defect and interatrial septal aneurysm. Chiari network can cause tricuspid valve regurgitation, atrial fibrillation, paradoxical embolism and bacterial embolism. We have performed surgery for Chiari network which was caused transient emboli and transient atrial fibrilllation. [ABSTRACT FROM AUTHOR]

Background Percutaneous closure is nowadays still deemed challenging in patent forame ovale (PFO) associated to multi-fenestrated atrial septal aneurysm (ASA). This anatomic arrangement is still considered a significant risk factor for recurrence of paradoxical embolism. Theoretically, transcatheter approach could be theoretically even more complex in the case of dextrocardia and visceral situs inversus. Case summary A 59-year-old man with history of migraine with aura and multiple cryptogenic strokes was referred for percutaneous closure of a PFO with associated ASA. He had been previously submitted to repeat attempt of percutaneous closure with not self-centering and self-centering devices that failed due to unfavorable anatomic characteristics (dextrocardia with situs viscerum inversus, huge ASA, multiple fenestrations, large PFO). Based on this "complex" anatomy, a sequential 2-step interventional approach aiming to reduce size and mobility of the atrial septal aneurysm with a suture-based approach (Noblestich™ EL, HeartStitch, Fountain Valley, CA, USA) and to close any eventual accessory fenestrations with a not self-centering occluding device was planned. At the end of the procedure, the ASA completely disappeared and no residual shunt was imaged at TEE bubble test. Discussion We describe a very rare case of symptomatic ASA-PFO in dextrocardia with situs viscerum inversus as well as an innovative approach to treat such complex anatomic setting by using the suture-based closure of a PFO to reduce size and mobility of an ASA in order to deploy dedicated not-self-centering occluding devices. [ABSTRACT FROM AUTHOR]

Introduction: A patent foramen ovale (PFO) may coexist with other potential embolic sources (PESs) in patients with embolic stroke of undetermined source (ESUS), leading to difficulty in attributing the stroke to either the PFO or other PESs. We aimed to investigate the prevalence and predictors of concomitant PESs in ESUS patients with PFOs. Methods: A retrospective cohort study was conducted in a tertiary stroke centre. Consecutive patients with ESUS and a concomitant PFO admitted between 2012 and 2021 were included in the study. Baseline characteristics and investigations as a part of stroke workup including echocardiographic and neuroimaging data were collected. PESs were adjudicated by 2 independent neurologists after reviewing the relevant workup. Results: Out of 1,487 ESUS patients, a total of 309 patients who had a concomitant PFO with mean age of 48.8 ± 13.2 years were identified during the study period. The median Risk of Paradoxical Embolism (RoPE) score for the study cohort was 6 (IQR 5–7.5). Of the 309 patients, 154 (49.8%) only had PFO, 105 (34.0%) patients had 1 other PES, 34 (11.0%) had 2 PES, and 16 (5.2%) had 3 or more PES. The most common PESs were atrial cardiopathy (23.9%), left ventricular dysfunction (22.0%), and cardiac valve disease (12.9%). The presence of additional PESs was associated with age ≥60 years (p < 0.001), RoPE score ≤6 (p≤0.001), and the presence of comorbidities including diabetes mellitus (p = 0.004), hypertension (p≤ 0.001), and ischaemic heart disease (p = 0.011). Conclusion: A large proportion of ESUS patients with PFOs had concomitant PESs. The presence of concomitant PESs was associated with older age and a lower RoPE score. Further, large cohort studies are warranted to investigate the significance of the PES and their overlap with PFOs in ESUS. [ABSTRACT FROM AUTHOR]

About 300 million adults undergo non-cardiac surgery annually. Although, in this setting, the incidence of perioperative stroke is low, the absolute number of patients experiencing a stroke is substantial. Furthermore, most patients with this complication will die or end up with severe disability. Covert brain infarctions are more frequent than overt strokes and are associated with postoperative delirium, cognitive decline, and cerebrovascular events at 1 year after surgery. Evidence shows that traditional stroke risk factors including older age, hypertension, and atrial fibrillation are also associated with perioperative stroke; previous stroke is the strongest risk factor for perioperative stroke. Increasing evidence also suggests the pathogenic role of perioperative events, such as hypotension, new atrial fibrillation, paradoxical embolism, and bleeding. Clinicians involved in perioperative care should be aware of this evidence on prevention strategies to improve patient outcomes after non-cardiac surgery. [ABSTRACT FROM AUTHOR]

Our study aims to report the findings of transesophageal echocardiography (TEE), Risk of Paradoxical Embolism (RoPE) score, the Patent Foramen Ovale-Associated Stroke Causal Likelihood (PASCAL) classification analyses, and follow-up results after percutaneous PFO closure in patients diagnosed with cryptogenic stroke. The medical records of patients with acute arterial ischemic stroke who were diagnosed with PFO by TEE and applied percutaneous PFO closure between 2020-2023 were reviewed. The echocardiography (Echo) score, the RoPE score, and the PASCAL classification were calculated for all patients as indicated in the literature. Newly developed arrhythmia, recurrent stroke, and cardiovascular death were recorded during follow-up. A total of 65 patients were included in the study. The median age was 41 years [range:33 -47]), the median RoPE score was 8, and the Echo score was 3. While 29.2% of the patients were in the possible group according to the PASCAL classification, 70.8% were in the probable group. We did not have any patients in the unlikely group. Recurrent ischemic stroke was detected in only two patients at a median follow-up of 12.1 months. No cardiac arrhythmia or cardiovascular death was observed. PFO closure in PFO-associated stroke patients was safe, with a low incidence of arrhythmia and cardiovascular and cerebrovascular events during the short -term follow-up. [ABSTRACT FROM AUTHOR]

A 20-year-old man with reduced mobility, from a car accident, presented to the Emergency Department of our hospital due to progressive dyspnea and heart palpitations the lasted three days. A bedside cardiac ultrasound and a Computed Tomography Pulmonary Angiogram (CTPA) were immediately performed, revealing strain of the right ventricle and pulmonary embolism (PE). The patient subsequently complained about abdominal pain and a Computed Tomography of the Abdominal Aorta (CTAO) revealed arterial embolism in the renal and splenic circulations, along with the right common femoral artery. Phlebography of inferior limbs exhibited deep vein thrombosis in the left popliteal vein. A percutaneous suction thrombectomy had been performed successfully. The patient underwent a transesophageal echocardiography with agitated saline test that revealed a patent foramen ovale (PFO), a diagnosis which explained the paradoxical embolism in both arterial and venous circulations. Paradoxical embolism is quite uncommon and should not be ignored in cases with indications of arterial embolism after PE. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to assess clinical outcomes and quality of life after PFO closure in patients with previous stroke/TIA of undetermined cause and in patients with other complex PFO-associated clinical conditions. Methods: Between July 2009 and December 2019 at our University Cardiology Department, 118 consecutive patients underwent a thorough diagnostic work-up including standardized history taking, clinical evaluation, full neurological examination, screening for thrombophilia, brain magnetic resonance imaging (MRI), ultrasound–Doppler sonography of supra-aortic vessels and 24 h ECG Holter monitoring. Anatomo-morphological evaluation using 2D transthoracic/transesophageal echocardiography (TTE/TEE) color Doppler and functional assessment using contrast TTE (cTTE) in the apical four-chamber view and contrast transcranial Doppler (cTCD) using power M-mode modality were performed to verify the presence, location and amount of right-to-left shunting via PFO or other extracardiac source. Completed questionnaires based on the Quality-of-Life Short Form-36 (QoL SF-36) and Migraine Disability Assessment (MIDAS) were obtained from the patients before PFO closure and after 12 months. Contrast TTE/TEE and cTCD were performed at dismission, 1, 6 and 12 months and yearly thereafter. Brain MRI was performed at 1-year follow-up in 54 patients. Results: Transcatheter PFO closure was performed in 106 selected symptomatic patients (mean age 41.7 ± 10.7 years, range 16–63, 65% women) with the following conditions: ischemic stroke (n = 23), transient ischemic attack (n = 22), peripheral and coronary embolism (n = 2), MRI lesions without cerebrovascular clinical events (n = 53), platypnea–orthodeoxia (n = 1), decompression sickness (n = 1) and refractory migraine without ischemic cerebral lesions (n = 4). The implanted devices were Occlutech Figulla Flex I/II PFO (n = 99), Occlutech UNI (n = 3), Amplatzer PFO (n = 3) and CeraFlex PFO occluders (n = 1). Procedures were performed under local anesthesia and rotational intracardiac monitoring (Ultra ICE) alone. The devices were correctly implanted in all patients. The mean fluoroscopy time was 15 ± 5 min (range = 10–45 min) and the mean procedural time was 55 ± 20 min (range = 35–90 min). The total occlusion rate at follow-up (mean 50 months, range 3–100) was 98.1%. No recurrent neurological events were observed in the long-term follow-up. Conclusions: The data collected in this study demonstrate that percutaneous PFO closure is a safe and effective procedure, showing long-term prevention of recurrent cerebrovascular events, significant reduction in migraine symptoms and substantial improvement in quality of life. [ABSTRACT FROM AUTHOR]