Systemic thromboembolism presenting as vertebral artery occlusion caused by patent foramen ovale with low D-dimer elevation

Abstract

Pulmonary embolism and deep vein thrombosis are often accompanied by an elevated D-dimer, and can cause paradoxical embolism in patients with a patent foramen ovale. We report the case of a patient with a patent foramen ovale in whom discovery of the embolic source was delayed by with low D-dimer elevation. A 52-year-old man was admitted with cerebellar infarction of the posterior inferior cerebellar artery resulting in a right thalamus infarction after 6 days, as well as a left vertebral artery acute occlusion after 8 days. He underwent thrombectomy by intravascular surgery. We diagnosed him with embolism from the removed thrombus, and transesophageal echocardiography revealed a patent foramen ovale. Pulmonary embolism and deep vein thrombosis were found upon further investigation, and he was started on anticoagulation therapy. Paradoxical embolism associated with patent foramen ovale is included in recent years as one etiology of embolic stroke of undetermined source (ESUS). Embolic source scrutiny is essential because of the cases with pulmonary embolism and deep vein thrombosis are existed with low D-dimer elevation.