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CASE REPORT
Year : 2019  |  Volume : 29  |  Issue : 4  |  Page : 172-174

Paradoxical embolism of stroke-related patent foramen ovale in a nonagenarian woman


Department of Cardiology, Tokushima Red Cross Hospital, Tokushima, Japan

Date of Web Publication27-Jan-2020

Correspondence Address:
Hiroya Takafuji
Department of Cardiology, Tokushima Red Cross Hospital, 103 Irinokuchi, Komatsushima-cho, Komatsushima, Tokushima, 773-8502
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_35_19

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  Abstract 


There are few clinical reports of elderly patients with paradoxical embolism in the current literature. Herein, we describe the case of a nonagenarian patient with paradoxical embolism of stroke-related patent foramen ovale (PFO). A 95-year-old woman was admitted to our hospital because of dysarthria. Her medical history included cerebral infarction, hypertension, and dyslipidemia. Magnetic resonance imaging performed in the emergency room revealed cerebral infarction of the left temporal lobe. After hospitalization in the neurosurgery department, we performed further clinical investigations to diagnose the type of stroke. There was no significant stenosis with plaque of the carotid and cerebral arteries, and there were no sources of cardiac embolism or an episode of atrial arrhythmia. Transesophageal echocardiography (TEE) showed PFO with separation and the Eustachian valve. In addition, spontaneous bidirectional shunt flow through the PFO was detected by TEE with the patient at rest. Ultrasonography of the leg vein revealed a thrombus in the deep vein. Therefore, she was diagnosed as having paradoxical embolism of stroke-related PFO and prescribed a direct oral anticoagulant (DOAC). This very rare case in which stroke-related PFO was diagnosed in a nonagenarian patient demonstrates that PFO is the cause of paradoxical embolism of stroke regardless of age.

Keywords: Old age, paradoxical embolism, patent foramen ovale


How to cite this article:
Takafuji H, Ogura R, Izumi T, Hosokawa S. Paradoxical embolism of stroke-related patent foramen ovale in a nonagenarian woman. J Cardiovasc Echography 2019;29:172-4

How to cite this URL:
Takafuji H, Ogura R, Izumi T, Hosokawa S. Paradoxical embolism of stroke-related patent foramen ovale in a nonagenarian woman. J Cardiovasc Echography [serial online] 2019 [cited 2020 Apr 8];29:172-4. Available from: http://www.jcecho.org/text.asp?2019/29/4/172/276895




  Introduction Top


Patent foramen ovale (PFO) is a general abnormality detected in approximately one-fourth of the adult population.[1],[2] In addition, it is well known that the abnormality is a cause of stroke, especially in younger individuals. Conversely, paradoxical embolism of stroke-related PFO is a cause of stroke in older individuals.[3] However, a clinical case of an elderly patient with paradoxical embolism is lacking from the literature. We describe the case of a nonagenarian patient with paradoxical embolism of stroke-related PFO.


  Case Report Top


A 95-year-old woman with hypertension and dyslipidemia was admitted to our hospital because of dysarthria. She had a history of hospitalization because of cerebral infarction 30 years previously. She was prescribed aspirin (100 mg), nifedipine (40 mg), telmisartan (20 mg), and atorvastatin (10 mg). On presentation, her consciousness was clear and she had no paralysis or paresthesia. However, she could not speak well. Her blood pressure was 193/103 mmHg, and the pulse rate was 85 beats/min. Electrocardiogram revealed a normal sinus rhythm, but laboratory data showed that the D-dimer level was increased (2.2 μg/ml). Emergency magnetic resonance imaging showed cerebral infarction of the left temporal lobe, and magnetic resonance angiography showed no significant stenosis of the major cerebral artery [Figure 1]. After hospitalization in the neurosurgery department, she was treated by heparin and edaravone. There was no significant stenosis with plaque of the carotid artery by the carotid duplex. In addition, there was no evidence of an episode of arrhythmia during hospitalization. On the transthoracic echocardiogram, the ejection fraction was normal without abnormalities of wall motion, and there was no significant valvular disease. Consequently, she was tentatively diagnosed as having embolic strokes of undetermined source (ESUS). Transesophageal echocardiography (TEE) showed no sources of cardiac embolism, such as an atrial appendage thrombus, appendage stasis with reduced flow velocities, or significant aortic arch atherosclerotic plaque. However, PFO with spontaneous bidirectional shunt and the prevalence of PFO separation were detected, whereas the patient was at rest [Figure 2]a and [Figure 2]b. Furthermore, the Eustachian valve was found [Figure 2]c. Ultrasonography of the leg vein revealed a thrombus in the deep vein. Finally, we diagnosed her as having cerebral infarction that occurred due to paradoxical embolism-related PFO.
Figure 1: Diffusion-weighted magnetic resonance imaging revealed infarction of the left temporal lobe, and magnetic resonance angiography showed no significant stenosis at major cerebral artery

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Figure 2: (a) Transesophageal echocardiography showed patent foremen ovale with bidirectional shunt by color Doppler. (b) Transesophageal echocardiography revealed the prevalence of patent foramen ovale separation at rest. (c) The Eustachian valve was found by transesophageal echocardiography

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Anticoagulant therapy (DOAC) was initiated 6 days after the acute ischemic event, as decided by the neurologist and cardiologist.


  Discussion Top


Most cases of cerebral infarction in elderly individuals are caused by atherosclerosis and cardioembolic sources, such as atrial fibrillation. Therefore, the possibility of ESUS-related PFO decreases with increasing age.[4],[5] However, the prevalence of a venous thrombus increases with the advancement of age. TEE is the gold standard approach for detecting embolic sources, but it is difficult to accurately diagnose the type of stroke in very old patients with stroke because there is a tendency to avoid the use of TEE in these patients. The transcranial Doppler bubble test is a useful tool for detecting a right-to-left shunt, such as PFO, but the anatomy of PFO can be confirmed using the only TEE.

Little is known about elderly patients with ESUS-related PFO. A previous case report described an 85-year-old man who had multiple embolic infarcts associated with PFO.[6] This present case is a very rare case in which ESUS-related PFO was diagnosed in a patient older than 90 years of age.

Percutaneous PFO closure in younger patients with ESUS-related PFO is more effective than conventional medical therapy alone to prevent cerebrovascular events.[7],[8],[9] However, the standard treatment of elderly patients with ESUS-related PFO remains unclear. We previously reported that percutaneous PFO closure in elderly patients with anatomically high-risk PFO is safe and effective.[10] In the present case, TEE revealed bidirectional shunt through the PFO and the prevalence of PFO separation with the patient at rest. These PFO findings are considered as high-risk morphology for the recurrence of embolic stroke. We treated our patient on a DOAC to prevent the recurrence of stroke. In the future, however, performing percutaneous PFO closure in elderly patients with ESUS-related PFO similarly to that in younger patients may be recommended. This treatment should be decided by a brain–heart team consisting of a neurologist and cardiologist and based on each individual case.

Meanwhile, atrial fibrillation increases with increasing age. The demonstration of a regular sinus rhythm during hospital monitoring does not absolutely exclude the occurrence of paroxysmal atrial fibrillation episodes. We consider that the implantation of a loop recorder might have eventually unmasked unrecognized episodes of atrial fibrillation.

In conclusion, we experienced a case of ESUS-related PFO in a very old patient. It demonstrated that regardless of age, PFO is the cause of paradoxical embolism of stroke.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Meissner I, Whisnant JP, Khandheria BK, Spittell PC, O'Fallon WM, Pascoe RD, et al. Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: the SPARC study. Stroke Prevention: Assessment of Risk in a Community. Mayo Clin Proc 1999;74:862-9.  Back to cited text no. 1
    
2.
Schneider B, Zienkiewicz T, Jansen V, Hofmann T, Noltenius H, Meinertz T. Diagnosis of patent foramen ovale by transesophageal echocardiography and correlation with autopsy findings. Am J Cardiol 1996;77:1202-9.  Back to cited text no. 2
    
3.
Handke M, Harloff A, Olschewski M, Hetzel A, Geibel A. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007;357:2262-8.  Back to cited text no. 3
    
4.
Cabanes L, Mas JL, Cohen A, Amarenco P, Cabanes PA, Oubary P, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography. Stroke 1993;24:1865-73.  Back to cited text no. 4
    
5.
Agmon Y, Khandheria BK, Meissner I, Gentile F, Whisnant JP, Sicks JD, et al. Frequency of atrial septal aneurysms in patients with cerebral ischemic events. Circulation 1999;99:1942-4.  Back to cited text no. 5
    
6.
Aarli SJ, Kråkenes J, Omdal TR, Waje-Andreassen U. Patent foramen ovale in an elderly male with multiple embolic infarcts. Clin Case Rep 2018;6:2403-6.  Back to cited text no. 6
    
7.
Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017;377:1011-21.  Back to cited text no. 7
    
8.
Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017;377:1022-32.  Back to cited text no. 8
    
9.
Søndergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017;377:1033-42.  Back to cited text no. 9
    
10.
Takafuji H, Hosokawa S, Ogura R, Hiasa Y. Percutaneous transcatheter closure of high-risk patent foramen ovale in the elderly. Heart Vessels 2019;34:1657-62.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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