Paradoxical embolism as initial manifestation of pulmonary arterial hypertension: a case report

Abstract

We report the case of a 34-year-old woman with paradoxical embolism due to the combination of patent foramen ovale and pulmonary arterial hypertension. She took norethisterone with ethinylestradiol for endometriosis. She visited our hospital with sudden dizziness and vomiting. Only gaze evoked nystagmus when looking left was observed, and National Institutes of Health Stroke Scale (NIHSS) was 0. Magnetic resonance imaging (MRI) of the head showed acute brain infarction in the left temporal lobe and left cerebellar hemisphere, and MR angiography (MRA) of the head and neck showed no stenosis or occlusion in the main arteries. Transthoracic echocardiography showed a suspicion of pulmonary hypertension, and contrast transesophageal echocardiography revealed right-to-left shunt via patent foramen ovale. Deep venous thrombosis was not detected. She was diagnosed with pulmonary arterial hypertension at the Department of Cardiology, and it is considered that paradoxical embolism was caused by the combination of patent foramen ovale and pulmonary arterial hypertension. She was treated with rivaroxaban for paradoxical embolism. In paradoxical embolism with patent foramen ovale, the possibility of pulmonary hypertension should be considered.