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Paradoxical Embolism


Presentation

  • We present a 47-year-old patient presenting with lower extremity ischemia secondary to paradoxical embolism. This case highlights the importance of evaluating for paradoxical embolism in otherwise-unexplained cases of acute limb ischemia.[ncbi.nlm.nih.gov]
Lower Extremity Pain
  • A 58-year-old male presented with severe substernal chest pain along with bilateral lower extremity pain. He was tachycardic, tachypneic, and hypoxic with tender right calf. Electrocardiogram showed ST elevation in anterior-lateral leads.[ncbi.nlm.nih.gov]
Limb Pain
  • A 72 year-old woman was admitted with a one-week history of weakness, right limb pain and progressive breathlessness.[ncbi.nlm.nih.gov]
Sneezing
  • […] positive-pressure ventilation Positive end-expiratory pressure Pulmonary hypertension from hypoxemia Myocardial infarction (MI) of the right side of the heart Valsalva-type maneuvers (forced expiration against a closed glottis), including urination, defecation, and sneezing[emedicine.medscape.com]
  • But if you have a small shunt, than this PFO might be closed a lot of the time, and might only be open if the RA pressure is increased by coughing or sneezing or bending over or hydration status or something.[mdcalc.com]
  • In the case of increased right atrial pressure exceeding left atrial pressure (as observed at the end of Valsalva maneuvers such as coughing, sneezing, squatting, defecation, or micturition), a transient right-to-left shunt may occur carrying particulate[onlinejacc.org]
  • […] platypnea and orthodeoxia associated with pneumonectomy or chronic liver disease; (10) neurosurgical procedures complicated by air embolism 45 ; and (11) Valsalvalike maneuvers in normal patients, 9, 45, 48, 51 including defecation, 5 micturition, and sneezing[jamanetwork.com]
Stupor
  • The symptoms included motor deficit in eight patients (50%), aphasia in one patient (6%), visual disturbances in four patients (25%), headache in four patients (25%), stupor in one patient (6%), and dysarthria in three patients (18%) ( Table 3 ).[synapse.koreamed.org]
Expressive Aphasia
  • Neurological examination revealed expressive aphasia, right hemianopsia, right central facial paralysis and right-sided paresis with a National institute of Health Stroke Scale of 19.[ncbi.nlm.nih.gov]
Paresis
  • The first case corresponds to a 49-year-old woman with sudden onset of dyspnea and syncope, followed by right upper extremity paresis, aphasia and dysarthria.[ncbi.nlm.nih.gov]
  • In the e me rge ncy room, she developed a left hemi paresis and right facial d roop, became progressively dyspneic, and was intubated.[kundoc.com]
Rabies
  • Almekhlafi MA, Wilton SB, Rabi DM, Ghali WA, Lorenzetti DL, Hill MD. Recurrent cerebral ischemia in medically treated patent foramen ovale: a meta-analysis. Neurology. 2009 ; 73 :89–97. Crossref Medline Google Scholar 18.[dx.doi.org]
Monoplegia
  • We present the case of a 63-year-old, right-handed man who presented to the emergency department with transitory ischemic accident (left superior extremity regressive monoplegia).[ncbi.nlm.nih.gov]

Workup

  • Further workup revealed the presence of a PFO with a large right-to-left shunt. After being put on antithrombotic therapy, she presented again at 13 gestational weeks with a new ischemic infarction in the vertebrobasilar territory.[ncbi.nlm.nih.gov]
  • Cardiac Workup of Ischemic Stroke. Cur. Cardiol. Rev. 6(3), 175-183 (2010). Yaghi S, Elkind MSV. Cryptogenic stroke: A diagnostic challenge. Neurology: Clin. Prac. 4(5), 386-393 (2014). Lechat P, Mas JL, Lascault G, et al.[openaccessjournals.com]
  • Patients should be educated regarding the adverse reactions from intravenous contrast agents that may occur in studies such as venography, arteriography, angiography, and cardiac catheterization (see Workup ).[emedicine.medscape.com]
Mural Thrombus
  • Complete etiologic work-up led to the discovery of both a patent foramen ovale associated with an septum interauricular aneurysm, and of a PVA without mural thrombus. The diagnosis of brain paradoxical embolism was retained.[ncbi.nlm.nih.gov]
Incomplete Right Bundle Branch Block
  • Her blood pressure was 60/40 mmHg, ECG showed inverted T waves in the precordial leads and incomplete right bundle branch block (RBBB).[ncbi.nlm.nih.gov]
  • An electrocardiograph showed a sinus rhythm but an incomplete right bundle branch block, indicating inferior ischemia. Pulmonary embolism was suspected; however, spiral computed tomography angiogram of the chest was negative.[healio.com]
T Wave Inversion
  • Cardiac enzyme levels were elevated, and an ECG revealed T-wave inversion in leads III, aVF, V1, and V2 with evolving ST-segment elevation in leads V3 through V5.[ncbi.nlm.nih.gov]

Treatment

  • Treatment choices consist of anticoagulation, thrombectomy, or thrombolysis. Choice of treatment is difficult but should be made quickly to reduce the possibility of adverse patient outcomes.[ncbi.nlm.nih.gov]
  • This approach is also used in the treatment of a present embolism, albeit at higher doses.[en.wikipedia.org]
  • Therapeutic options include surgical treatment with thrombectomy or medical treatment with heparin or thrombolysis.[em-consulte.com]

Prognosis

  • In addition, after hospital discharge, the prognosis appears to depend largely on the underlying disease (sepsis, tumor, heart disease, etc.) and not on the thrombus itself. ( 5 ) When associated with cardiac septum defects, RHT poses a risk of paradoxical[scielo.br]
  • Prognosis PDE generally has a good prognosis when it is not complicated. Morbidity and mortality are increased in patients with PDE and PE, depending on the size of the embolus and end-organ lodgment.[emedicine.medscape.com]
  • Keywords Embolism; Cryptogenic stroke Introduction Stroke is the number one cause of disability in developed countries and the third cause of mortality and up to 15-30% of ischemic strokes are caused by a cardiac source of emboli being associated with poor prognosis[openaccessjournals.com]
  • CT may only be diagnostic in the acute setting as gas is absorbed rapidly 4 use of lung windows may help increase detection Treatment and prognosis Treatment is typically supportive although there is increasing evidence for the use of hyperbaric oxygen[radiopaedia.org]

Etiology

  • The diagnosis of paradoxical embolism with intraoperative identification of the etiologic site of the deep venous thrombosis is a rare event.[ncbi.nlm.nih.gov]
  • In view of the patient's history of multiple recurrent transient ischemic attacks, likely due to cardioembolic etiology (paradoxical embolism), it was decided to start anticoagulation therapy.[revportcardiol.org]

Epidemiology

  • We review the epidemiology, pathophysiology, and management of pulmonary AVMs in relation to stroke risk. Copyright 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • Strokes in young adults: epidemiology and prevention. Vascul. Heal. Risk. Manag. 11, 157-164 (2015). Windecker S, Stortecky S, Meier B. Paradoxical Embolism. J. Am. Coll. Cardiol. 64(4), 403-415 (2014).[openaccessjournals.com]
  • […] and genitourinary surgical procedures Trauma Intracardiac communication of the venous and arterial circulations can lead to PDE and may occur via the following: PFO ASD Pulmonary arteriovenous malformation VSD Ebstein anomaly Patent ductus arteriosus Epidemiology[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • We review the epidemiology, pathophysiology, and management of pulmonary AVMs in relation to stroke risk. Copyright 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • Paradoxical embolisms represent two percent of arterial emboli. [2] Pathophysiology [ edit ] Passage of a clot (thrombus) from a systemic vein to a systemic artery.[en.wikipedia.org]
  • Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol 2005; 46:1768 DOI: 10.1016/j.jacc.2005.08.038; Loscalzo J.[icfjournal.org]
  • Thus it is not surprising that we also found a subset of patients with MI caused by this pathophysiology.[jstage.jst.go.jp]

Prevention

  • Although anticoagulation is necessary to prevent paradoxical emboli, the hematologic disturbances and the most appropriate therapy in these patients warrant further investigation. Copyright 2016 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • On the basis of data from 3 recently published, randomized, clinical trials involving stroke prevention in PFO patients, a medical therapeutic strategy was favored over percutaneous PFO closure to prevent recurrent paradoxical embolism.[dx.doi.org]
  • Therapeutic Options to Prevent Stroke or TIA in PFO Patients Primary Prevention Prevention strategies for a first-time stroke do not differ in patients with respect to PFO status.[circ.ahajournals.org]

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