The successful surgical treatment of a paradoxical embolus to the carotid bifurcation

Abstract

Paradoxical embolism is a rare cause of ischemic stroke. We report the case of a 67-year-old man who had a saddle embolus to the carotid bifurcation successfully treated with emergency embolectomy. Transesophageal echocardiogram revealed a large patent foramen ovale and an easily demonstrable right-to-left shunt. Subsequent investigations revealed proximal deep venous thrombosis in the left femoral and popliteal veins and multiple pulmonary emboli. Long-term anticoagulation was instituted for the diagnosis of paradoxical embolism. The patient's recovery was uneventful, and he remained neurologically intact. A literature review emphasizes the role of transesophageal echocardiography and suggests that paradoxical embolism may be a more common cause of stroke than previously thought.

Saddle thromboembolus of the supra-aortic arch vessels resulting in brain infarction

“…There are multiple reports involving saddle thromboembolism of the lower aorta vessels and carotid artery bifurcations 1, 2, 3. However, a saddle thromboembolism of the supra-aortic arch vessels, especially one of this magnitude, is very rare and not well reported in the literature.…”

Carotid Embolectomy in the Treatment of a Paradoxical Embolus

“…Previous to this case, only two other reported cases of surgical management have been described. McKinney et al 3 reported the case of a 67-year-old man with a saddle embolus to the carotid bifurcation and a demonstrable large patent foramen ovale, as well as DVT and multiple pulmonary emboli treated successfully with embolectomy. The authors chose not to repair the patient's foramen ovale via surgical closure because of what they termed the uncertain risks and benefits of PFO closure versus long-term anticoagulation.…”

“…2 Surgical management of PDE in the extracranial cerebrovascular system has been reported previously on two occasions with successful results (Table 1). 3,4 We report an additional case of a PDE that was surgically removed from the left common carotid artery.…”

Repeated Thrombus Formation Immediately Following Carotid Endarterectomy-Case Report-

“…Paradoxical embolism is a rare cause of stroke, 8) but patients with stroke may have a patent foramen ovale, suggesting investigation of intracardiac disorders. 7) Our patient did not have any cardiac disorders, but thrombus was repeatedly found at the cervical bifurcation by ultrasonography following CEA and before the anticoagulant therapy had become effective.…”