22. European Stroke Conference 604 © 2013 S. Karger AG, Basel Scientific Programme 22 Interesting and challenging cases Paradoxical embolism without patent foramen ovale I. CANAVERO1, A. CAVALLINI2, E. CANDELORO3, M. MAURELLI4, M.F. DENARO5, M.C. SPINELLI6, F. RECUSANI7, G. MICIELI8 NATIONAL NEUROLOGIC INSTITUTE FOUNDATION IRCCS C. MONDINO, PAVIA, IT-ALY1, NATIONAL NEUROLOGIC INSTITUTE FOUNDATION IRCCS C. MONDINO, PAVIA, ITALY2, NATIONAL NEUROLOGIC INSTITUTE FOUNDATION IRCCS C. MONDINO, PA-VIA, ITALY3, NATIONAL NEUROLOGIC INSTITUTE FOUNDATION IRCCS C. MONDINO, PAVIA, ITALY4, NATIONAL NEUROLOGIC INSTITUTE FOUNDATION IRCCS C. MONDI-NO, PAVIA, ITALY5, NATIONAL NEUROLOGIC INSTITUTE FOUNDATION IRCCS C. MON-DINO, PAVIA, ITALY6, IRCCS POLICLINICO SAN MATTEO, PAVIA, ITALY7, NATIONAL NEUROLOGIC INSTITUTE FOUNDATION IRCCS C. MONDINO, PAVIA, ITALY8 Background: In some cases of cryptogenetic stroke, clinical features (young patients, absence of the classical vascular risk factors) and anamnestic data (typology of onset, association with Valsalva maneuver) suggest a paradoxical embolism, driving diagnostic process primarily in search of pat-ent foramen ovale, the most frequent cause of shunt between venous and arterial circulation, whose medical treatment has been under debate since many years. Case report: a 49 years-old man, without clinical history, after defecation developed right hemi-plegia from multiple left-hemisferic ischemic lesions. Transesophageal echocardiography revealed not a PFO but “a late passage of bubbles, consistent with a shunt located next to pulmonary veins”. Contrast-transcranial Doppler proved the significance of this shunt, with shower effect during Val-salva maneuver. Doppler sonography of legs reported no signs of deep venous thrombosis but “nota-ble venous ectasia, a pro-thrombotic condition”. According to anamnestic and instrumental findings, it has been hypothesized a paradoxical embolism; for secondary prevention of ischemic recurrences it has been prescribed long-term single-antiplatelet therapy. Conclusions: When history and clinical features are indicative, without other reliable etiopathoge-netic explanations or risk factors, the absence of PFO does not exclude paradoxical embolism. The case highlights some interesting topics, that have no exhaustive answers in current literature: - How to quantify the embolic potential of a shunt? Is Contrast-transcranial Doppler a reliable “stroke-sim-ulation” test, able to support the hypothesis of paradoxical embolism?; - In the absence of specific guidelines, what should be the secondary prevention strategy for a shunt that is different from PFO? 21 Interesting and challenging cases Pulmonary AVM causing paradoxical embolism and stroke in an older patient M. Bhargava1, M. Tafti2 Basildon and Thurrock University Hospital NHS Foundation Trust, Basildon, UNITED KINGDOM1, Basildon and Thurrock University Hospital NHS Foundation Trust, Basildon, UNIT-ED KINGDOM2 Background: Around 30% of strokes are labelled as cryptogenic as no obvious cause is found de-spite extensive investigations. It is however important to thoroughly investigate for rare causes irrespective of age, if clinically indicated, to prevent future recurrence and to provide appropriate treatment. We present a rare case of Pulmonary AVM causing paradoxical embolism and stroke in an older patient Case History: A 67 year old Caucasian gentleman presented to the Stroke unit with a one day histo-ry of sudden onset unsteadiness. On examination, he was found to have left sided cerebellar signs. Subsequent MRI confirmed multiple posterior circulation infarcts suggestive of embolization. He was also noted to very hypoxic with saturations between 84-86% on air. He also had multiple peri-oral telangiectasia. The chest x-ray showed a large round coin shaped lesion on left side raising pos-sibility of malignancy. CT chest confirmed presence of large pulmonary AVM with a thrombus in it. His physical examination and subsequent investigations were suggestive of Hereditary Haemorrhag-ic Telangiectasis with Pulmonary AVM causing paradoxical embolization. He was started on anticoagulation and underwent successful embolization of the AVM. Discussion: Pulmonary AVMs are increasingly being recognised as rare causes of stroke in young patients but it is very unusual for them to cause symptoms in an older age group (> 65 years). This emphasizes the importance of having an open mind and undertaking investigation for rarer causes of stroke, if clinically indicated.
Karger_ESC London_2013
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