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Pulmonary embolism and patent foramen ovale, augmented risk for paradoxical embolism?
1 Department of Critical Care Medicine, Navarre University Hospital, Pamplona, Spain
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Pablo Lasa-Berasain
Department of Critical Care Medicine, Navarre University Hospital, Pamplona,
Spain
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Article ID: 101353Z01PL2022
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Lasa-Berasain P, Parra MG, Lucea JR, Polanco JL, Baquero PA. Pulmonary embolism and patent foramen ovale, augmented risk for paradoxical embolism? Int J Case Rep Images 2022;13(2):168–170.ABSTRACT
No Abstract
Keywords: Paradoxical stroke, Patent foramen oval, Pulmonary embolism
Case Report
A 72-year-old man who had been discharged earlier in the day from the emergency room (ER) on anticoagulation therapy with the diagnosis of left popliteal territory deep vein thrombosis (DVT), was brought back into the ER, intubated and hemodynamically unstable, after an episode of resolved syncope, followed by agitation and severe desaturation. Past medical history was marked by ongoing chemotherapy treatment for stage 4 intrahepatic cholangiocarcinoma. Pulmonary embolism was suspected, among other non-traumatic causes of syncope: arrhythmias, acute myocardial infarction, aortic stenosis, vasovagal reflex, orthostatic hypotension, and others. Due to difficult peripheral venous access, a femoral central venous catheter (CVC) was placed for sedoanalgesia and vasopressor drip. 12-Lead electrocardiogram was performed showing sinus tachycardia with S1Q3T3 sign (Figure 1). Point of care ultrasound (POCUS) showed a dilated right ventricle and McConnell’s sign. It also revealed a patent foramen ovale (PFO) with the CVC crossing to the left atrium, in the context of right to left shunt (Figure 2). Arterial blood gas and lab tests were performed (Table 1). Thoracic computed tomography (CT) scan confirmed bilateral central pulmonary embolism (PE) (Figure 3). Brain computed tomography (CT) scan was performed in the absence of neurological examination to aid in therapeutic effort adequacy planning, which ruled out signs of acute paradoxical stroke. After intensive care unit (ICU) admission, percutaneous thrombectomy and thrombolysis were performed due to persistent hemodynamic instability. The patient’s condition improved and he was discharged six days after admission in the ICU. No neurological symptoms were reported during evolution.
Discussion
Paradoxical embolism through a PFO accounts for some 54% of cases of cryptogenic stroke [1] and it can be a potential complication found simultaneously or closely after PE presentation [2]. This is favored in the presence of PFO and high or intermediate risk PE, characterized by elevated right circulation pressures with right to left atrial shunt [2],[3]. Quick PFO ruled out with transthoracic echocardiogram could potentially serve as a negative predictive value. In our case we encountered the diagnoses of PFO by chance during our POCUS examination and chest CT. Brain CT was performed to rule out acute embolic stroke in the initial work-up.
Conclusion
The risk of paradoxical embolism stroke is augmented in severe PE cases with associated PFO, but more studies are needed to aid in the diagnostic approach and clinical management of these cases.
REFERENCES
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Kakkos SK, Geroulakos G. Economy class stroke syndrome: Case report and review of the literature. Eur J Vasc Endovasc Surg 2004;27(3):239–43. [CrossRef]
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Le Moigne E, Timsit S, Ben Salem D, et al. Patent foramen ovale and ischemic stroke in patients with pulmonary embolism: A prospective cohort study. Ann Intern Med 2019;170(11):756–63. [CrossRef]
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Tassi R, Guideri F, Acampa M, Domenichelli C, Martini G. Acute ischemic stroke and concomitant massive pulmonary embolism: A challenge. Neurol Sci 2021;42(11):4777–80. [CrossRef]
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SUPPORTING INFORMATION
Author Contributions
Pablo Lasa-Berasain - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Mario García Parra - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Javier Ruíz Lucea - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Joaquín Lobo Palanco - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Pilar Anguiano Baquero - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Guarantor of SubmissionThe corresponding author is the guarantor of submission.
Source of SupportNone
Consent StatementWritten informed consent was obtained from the patient for publication of this article.
Data AvailabilityAll relevant data are within the paper and its Supporting Information files.
Conflict of InterestAuthors declare no conflict of interest.
Copyright© 2022 Pablo Lasa-Berasain et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.
