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Persistent right to left shunt post PFO closure for recurrent CVAs
Cardiovascular Radiation Medicine 4 (2003) 51
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Persistent right to left shunt post PFO closure for recurrent CVAs R. Lew, L. Satler, A. Pichard, M. Slack, K. Kent, J. Laird, W. Suddath, J. Sharretts, R. Waksman* Washington Hospital Center, 110 Irving Street, NW Suite 4B-1, Washington, DC 20010, USA
1. History A 34-year-old female presented with left CVA 6/01 and cerebellar CVA 2/02. The patient was initially diagnosed with patent foramen ovale during investigation of first CVA. No other potential etiologies were identified, and there was recurrent CVA despite anticoagulation therapy.
2. Investigations
Fig. 1. Amplatzer PFO closure device.
Prothrombotic screen was negative and PFO was diagnosed with positive bubble study on echocardiography. CT of the brain showed old right frontal infarct, cerebellar infarct and mild residue deficit from cerebellar infarct.
3. Post PFO closure There were no further neurological events, while bubble echo study continues to show right to left shunting after 9 months, despite good positioning of PFO occluder device (Fig. 1).
Fig. 2. Left pulmonary vasculature normal.
4. Follow-up Further investigations revealed large pulmonary arteriovenous malformation (AVM) (Fig. 2) as a possible source of a positive echo bubble contrast study and no further neurological events. Bubble echo study now negative for right to left shunting and ‘‘cryptogenic stroke’’ secondary to PFO or large pulmonary AVM (Figs. 3 and 4).
* Corresponding author. Tel.: +1-202-877-8575; fax: +1-202-877-2715. E-mail address: [email protected] (R. Waksman). 1522-1865/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S1522-1865(03)00140-9
Fig. 3. Right lower lobe AVM.
Fig. 4. AVM occluded by three Gianturco coils.
Image of the Issue
Persistent right to left shunt post PFO closure for recurrent CVAs R. Lew, L. Satler, A. Pichard, M. Slack, K. Kent, J. Laird, W. Suddath, J. Sharretts, R. Waksman* Washington Hospital Center, 110 Irving Street, NW Suite 4B-1, Washington, DC 20010, USA
1. History A 34-year-old female presented with left CVA 6/01 and cerebellar CVA 2/02. The patient was initially diagnosed with patent foramen ovale during investigation of first CVA. No other potential etiologies were identified, and there was recurrent CVA despite anticoagulation therapy.
2. Investigations
Fig. 1. Amplatzer PFO closure device.
Prothrombotic screen was negative and PFO was diagnosed with positive bubble study on echocardiography. CT of the brain showed old right frontal infarct, cerebellar infarct and mild residue deficit from cerebellar infarct.
3. Post PFO closure There were no further neurological events, while bubble echo study continues to show right to left shunting after 9 months, despite good positioning of PFO occluder device (Fig. 1).
Fig. 2. Left pulmonary vasculature normal.
4. Follow-up Further investigations revealed large pulmonary arteriovenous malformation (AVM) (Fig. 2) as a possible source of a positive echo bubble contrast study and no further neurological events. Bubble echo study now negative for right to left shunting and ‘‘cryptogenic stroke’’ secondary to PFO or large pulmonary AVM (Figs. 3 and 4).
* Corresponding author. Tel.: +1-202-877-8575; fax: +1-202-877-2715. E-mail address: [email protected] (R. Waksman). 1522-1865/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved. doi:10.1016/S1522-1865(03)00140-9
Fig. 3. Right lower lobe AVM.
Fig. 4. AVM occluded by three Gianturco coils.