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Patent Foramen Ovale and Embolic Stroke “En Flagrant Délit”
CASE REPORT
Patent Foramen Ovale and Embolic Stroke “En Flagrant De´lit” Abdallah K. Alameddine, MD, Victor K. Alimov, MD and Daniel Engelman, MD
Abstract: Proof of a causal relationship between a patent fossa ovale and cryptogenic stroke has been controversial (Yasaka et al, Intern Med 2005;44:434 – 8). The authors identified 1 patient in whom the presence of a large migrating thrombus through a moderate-size patent fossa ovale was caught “en flagrant de´lit,” which suggests a direct pathogenic role. Key Indexing Terms: Stroke; Paradoxical embolus; Patent fossa ovale. [Am J Med Sci 2012;343(4):342.]
A
CLINICAL SUMMARY
54-year-old obese man, height 6 feet, weight 280 lbs, presented with exertional dyspnea of 2 weeks duration. One-year before this admission, the patient had a cerebellar stroke, of unknown cause, from which he had partial recovery. At that presentation, his carotid ultrasound studies and coronary angiogram were normal. His medications included a beta-blocker and diuretic for stable hypertension and aspirin. The ventilation perfusion scan showed multiple perfusion defects compatible with pulmonary emboli. A 4-cm long thrombus was demonstrated in transit straddling a moderate-size patent fossa ovale (PFO) of 4 mm diameter on transesophageal echocardiography (Figure 1, arrow head). The mobile thrombus occupied a large portion of the right atrium. The left ventricular ejection fraction was 55%, and the right ventricle was mildly dilated with mild pulmonary artery hypertension. The Doppler ultrasound of the right leg showed deep vein thrombosis. The hazard of precipitating pulmonary or systemic embolization with thrombolysis was presumed too high. Therefore, the PFO was surgically closed and the multilobulated clot was removed. The postoperative transesophageal echocardiography demonstrated no residual clot. The patient was discharged on warfarin 10 days after surgery in good condition, and he remained free of relapse 8 years later. As the patient had no known indicators of prothrombotic abnormalities on hematologic workup, the placement of a caval filter was not carried out.
From the Cardiac Surgery Division, Baystate Medical Center, Springfield, Massachusetts. Submitted August 15, 2011; accepted in revised form October 5, 2011. Correspondence: A.K. Alameddine, MD, Cardiac Surgery Division, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01107 (E-mail: [email protected]).
342
FIGURE 1. Transesophageal echocardiography demonstrates a 4-cm long thrombus in transit straddling a moderate, 4 mm diameter sized patent fossa ovale (PFO).
DISCUSSION This case argues favorably for the likelihood of this patient’s earlier, so-called cryptogenic stroke, being secondary to the PFO. The available literature suggests that the hazard of clinically significant systemic embolism is high in patients who have a PFO.1 This case also reinforces the importance of echocardiography which should be recognized as critically important diagnostic imaging study in the workup for stroke of unknown cause.2 In this case, it led to the correct diagnosis and a good clinical outcome and caught a paradoxical embolus “red-handed.” REFERENCES 1. Handke M, Harloff A, Olschewski M, et al. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007;357:2262– 8. 2. Hamilton-Craig C, Sestito A, Natale L, et al. Contrast transoesophageal echocardiography remains superior to contrast-enhanced cardiac magnetic resonance imaging for the diagnosis of patent foramen ovale. Eur J Echocardiogr 2011;12:222–7.
The American Journal of the Medical Sciences • Volume 343, Number 4, April 2012
Patent Foramen Ovale and Embolic Stroke “En Flagrant De´lit” Abdallah K. Alameddine, MD, Victor K. Alimov, MD and Daniel Engelman, MD
Abstract: Proof of a causal relationship between a patent fossa ovale and cryptogenic stroke has been controversial (Yasaka et al, Intern Med 2005;44:434 – 8). The authors identified 1 patient in whom the presence of a large migrating thrombus through a moderate-size patent fossa ovale was caught “en flagrant de´lit,” which suggests a direct pathogenic role. Key Indexing Terms: Stroke; Paradoxical embolus; Patent fossa ovale. [Am J Med Sci 2012;343(4):342.]
A
CLINICAL SUMMARY
54-year-old obese man, height 6 feet, weight 280 lbs, presented with exertional dyspnea of 2 weeks duration. One-year before this admission, the patient had a cerebellar stroke, of unknown cause, from which he had partial recovery. At that presentation, his carotid ultrasound studies and coronary angiogram were normal. His medications included a beta-blocker and diuretic for stable hypertension and aspirin. The ventilation perfusion scan showed multiple perfusion defects compatible with pulmonary emboli. A 4-cm long thrombus was demonstrated in transit straddling a moderate-size patent fossa ovale (PFO) of 4 mm diameter on transesophageal echocardiography (Figure 1, arrow head). The mobile thrombus occupied a large portion of the right atrium. The left ventricular ejection fraction was 55%, and the right ventricle was mildly dilated with mild pulmonary artery hypertension. The Doppler ultrasound of the right leg showed deep vein thrombosis. The hazard of precipitating pulmonary or systemic embolization with thrombolysis was presumed too high. Therefore, the PFO was surgically closed and the multilobulated clot was removed. The postoperative transesophageal echocardiography demonstrated no residual clot. The patient was discharged on warfarin 10 days after surgery in good condition, and he remained free of relapse 8 years later. As the patient had no known indicators of prothrombotic abnormalities on hematologic workup, the placement of a caval filter was not carried out.
From the Cardiac Surgery Division, Baystate Medical Center, Springfield, Massachusetts. Submitted August 15, 2011; accepted in revised form October 5, 2011. Correspondence: A.K. Alameddine, MD, Cardiac Surgery Division, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01107 (E-mail: [email protected]).
342
FIGURE 1. Transesophageal echocardiography demonstrates a 4-cm long thrombus in transit straddling a moderate, 4 mm diameter sized patent fossa ovale (PFO).
DISCUSSION This case argues favorably for the likelihood of this patient’s earlier, so-called cryptogenic stroke, being secondary to the PFO. The available literature suggests that the hazard of clinically significant systemic embolism is high in patients who have a PFO.1 This case also reinforces the importance of echocardiography which should be recognized as critically important diagnostic imaging study in the workup for stroke of unknown cause.2 In this case, it led to the correct diagnosis and a good clinical outcome and caught a paradoxical embolus “red-handed.” REFERENCES 1. Handke M, Harloff A, Olschewski M, et al. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007;357:2262– 8. 2. Hamilton-Craig C, Sestito A, Natale L, et al. Contrast transoesophageal echocardiography remains superior to contrast-enhanced cardiac magnetic resonance imaging for the diagnosis of patent foramen ovale. Eur J Echocardiogr 2011;12:222–7.
The American Journal of the Medical Sciences • Volume 343, Number 4, April 2012