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Nakiri M, Ueda K, Hoshino R, Ito N, Kurose H, Nohara S, Muraki K, Hattori C, Ogo E, Igawa T. Prostate brachytherapy seed migration to the right renal artery due to right-to-left shunting across a patent foramen ovale. IJU Case Rep 2024; 7:221-224. [PMID: 38686070 PMCID: PMC11056261 DOI: 10.1002/iju5.12707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/09/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction The seeds used in brachytherapy for prostate cancer may migrate through the surrounding venous plexus to other sites in the body, most commonly to the pulmonary vasculature. Case presentation A 78-year-old Japanese man received iodine-125 low-dose-rate prostate brachytherapy. Computed tomography revealed that one seed had migrated to the right kidney. No seed was observed in the ureter upon ureteroscopy. Transesophageal echocardiography confirmed a right-to-left shunt due to a patent foramen ovale, suggesting that the seed had migrated into the right renal artery. Three years after treatment, no recurrence of prostate cancer and no adverse events due to seed migration or due to the patent foramen ovale occurred. Conclusion Arteriovenous malformations and a right-to-left shunt should be suspected if a brachytherapy seed has migrated to an artery of the systemic circulatory system.
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Affiliation(s)
- Makoto Nakiri
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Kosuke Ueda
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Ryuji Hoshino
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Naoki Ito
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Hirofumi Kurose
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Shoichiro Nohara
- Division of Cardiovascular Medicine, Department of Internal MedicineKurume University School of MedicineKurumeJapan
| | - Koichiro Muraki
- Department of RadiologyKurume University School of MedicineKurumeJapan
| | - Chikayuki Hattori
- Department of RadiologyKurume University School of MedicineKurumeJapan
| | - Etsuyo Ogo
- Department of RadiologyKurume University School of MedicineKurumeJapan
| | - Tsukasa Igawa
- Department of UrologyKurume University School of MedicineKurumeJapan
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Wang S, He R, Xia J, Gu W, Li J, Yang H, Huang Q. Antithrombin deficiency caused by SERPINC1 gene mutation in white matter lesions: A case report. Medicine (Baltimore) 2024; 103:e37721. [PMID: 38579030 PMCID: PMC10994456 DOI: 10.1097/md.0000000000037721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/05/2024] [Indexed: 04/07/2024] Open
Abstract
RATIONALE White matter lesions (WMLs) are structural changes in the brain that manifest as demyelination in the central nervous system pathologically. Vasogenic WMLs are the most prevalent type, primarily associated with advanced age and cerebrovascular risk factors. Conversely, immunogenic WMLs, typified by multiple sclerosis (MS), are more frequently observed in younger patients. It is crucial to distinguish between these 2 etiologies. Furthermore, in cases where multiple individuals exhibit WMLs within 1 family, genetic testing may offer a significant diagnostic perspective. PATIENT CONCERNS A 25-year-old male presented to the Department of Neurology with recurrent headaches. He was healthy previously and the neurological examination was negative. Brain magnetic resonance imaging (MRI) showed widespread white matter hyperintensity lesions surrounding the ventricles and subcortical regions on T2-weighted and T2 fluid-attenuated inversion recovery images, mimicking immunogenic disease-MS. DIAGNOSES The patient was diagnosed with a patent foramen ovale, which could explain his headache syndrome. Genetic testing unveiled a previously unidentified missense mutation in the SERPINC1 gene in the patient and his father. The specific abnormal laboratory finding was a reduction in antithrombin III activity, and the decrease may serve as the underlying cause for the presence of multiple intracranial WMLs observed in both the patient and his father. INTERVENTIONS The patient received percutaneous patent foramen ovale closure surgery and took antiplatelet drug recommended by cardiologists and was followed up for 1 month and 6 months after operation. OUTCOMES While the lesions on MRI remain unchanging during follow-up, the patient reported a significant relief in headaches compared to the initial presentation. LESSONS This case introduces a novel perspective on the etiology of cerebral WMLs, suggesting that hereditary antithrombin deficiency (ATD) could contribute to altered blood composition and may serve as an underlying cause in certain individuals with asymptomatic WMLs.
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Affiliation(s)
- Song Wang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Runcheng He
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Jian Xia
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Wenping Gu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Jing Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Qing Huang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- Clinical Research Center for Cerebrovascular Disease of Hunan Province, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, People’s Republic of China
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Yu K, Li Y, Wang C, Fu J, Hu Y, Wang L, Zhang J. Efficacy of interventional closure therapy on cryptogenic stroke with coexisting patent foramen ovale in young patients and its impact on serum fibrinogen and D-dimer levels. Int J Neurosci 2023:1-8. [PMID: 38130242 DOI: 10.1080/00207454.2023.2298714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To explore the efficacy of interventional closure therapy in young patients with cryptogenic stroke and coexisting patent foramen ovale and analyze its impact on serum fibrinogen and D-dimer levels. METHODS All subjects in this study were young stroke patients with PFO. After excluding patients who did not meet the inclusion criteria, they were registered and divided into two groups based on the treatment method: the closure group and the medical group. RESULTS There were no significant differences in basic clinical data between the two groups, indicating comparability (p > 0.05). The closure group showed better heart function after treatment compared to the medical group, with significant differences (p < 0.05). Headache symptoms in the closure group were less severe than those in the medical group after treatment, with significant differences (p < 0.05). Laboratory indicators in the closure group were better than those in the medical group after treatment, with significant differences (p < 0.05). Serum fibrinogen and D-dimer levels in the closure group were lower than those in the medical group after treatment, with significant differences (p < 0.05). CONCLUSION Interventional closure therapy demonstrated positive effects on young patients with cryptogenic stroke and coexisting PFO, showing improvements in heart function, headache symptoms, and blood coagulation parameters. While the study suggests potential benefits, cautious interpretation is warranted, given the observational study design. Further research with a larger sample size and long-term follow-up is needed to validate these findings.
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Affiliation(s)
- Kai Yu
- Department Five of Cardiovasology, Cangzhou Central Hospital, Cangzhou, China
| | - Yaoru Li
- Department Five of Neurology, Cangzhou Central Hospital, Cangzhou, China
| | - Ce Wang
- Dongguang Hospital of Traditional Chinese Medicine, Dongguang, China
| | - Jinguo Fu
- Department Five of Cardiovasology, Cangzhou Central Hospital, Cangzhou, China
| | - Yaping Hu
- Department Five of Cardiovasology, Cangzhou Central Hospital, Cangzhou, China
| | - Lei Wang
- Department Five of Cardiovasology, Cangzhou Central Hospital, Cangzhou, China
| | - Jun Zhang
- Department Five of Cardiovasology, Cangzhou Central Hospital, Cangzhou, China
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Zhang L, Zhang H, Zhou X, Zhao J, Wang X. Bibliometric Analysis of Research on Migraine-Stroke Association from 2013 to 2023. J Pain Res 2023; 16:4089-4112. [PMID: 38058980 PMCID: PMC10697147 DOI: 10.2147/jpr.s438745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/22/2023] [Indexed: 12/08/2023] Open
Abstract
Background Both migraine and stroke heavily burden individuals, health systems, and society. The migraine-stroke association is of concern and has been studied widely. Our objective is to explore and overview the current research status and emerging trends. Materials and Methods Studies on migraine-stroke association from January 2013 to May 2023 were retrieved and screened from the Web of Science Core Collection (WOSCC) database. Records fulfilling the selection criteria were downloaded and imported into CiteSpace for data mining and visualization. Results A total of 862 papers on migraine-stroke association were included. Annual publications grew slowly. The United States and European countries dominated research in this area. Harvard University published the largest number of articles, while the University of London was most active with other institutions. Ayata Cenk contributed the most articles, while KURTH T and NEUROLOGY were co-cited most. Research hotspots included migraine with aura, ischemic stroke, patent foramen ovale, cortical spreading depolarization, meta-analysis, cross-sectional study, and risk factors. Pathophysiology and small vessel disease represented research frontiers and emerging trends. Conclusion Our study scientifically outlines the migraine-stroke association over the past decade, presenting useful information.
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Affiliation(s)
- Long Zhang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
- Department of Traditional Chinese Medicine, Zibo TCM-Integrated Hospital, Zibo, Shandong, People’s Republic of China
| | - Hongyan Zhang
- Department of Traditional Chinese Medicine, Shanghai Sixth People’s Hospital, Shanghai, People’s Republic of China
- Shaanxi Key Laboratory of Research on TCM Physical Constitution and Diseases Prevention and Treatment, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, People’s Republic of China
| | - Xue Zhou
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Jing Zhao
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Xingchen Wang
- Division of Neurology, the Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
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Khalid N, Abdullah M, Ozgur SS, Elkattawy S, Shamoon F. Managing Patent Foramen Ovale (PFO) in Adults With Cryptogenic Stroke and Lymphoma: A Multidisciplinary Perspective. Cureus 2023; 15:e40316. [PMID: 37448395 PMCID: PMC10337876 DOI: 10.7759/cureus.40316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Cryptogenic strokes are strokes with no clear underlying cause. Patent foramen ovale (PFO) is believed to be one of the causes of cryptogenic strokes. To manage such cases, closing the PFO is usually considered an option. We report a case of a middle-aged male with lymphoma who presented with an altered mental status due to a stroke, which, on investigation, was found to be due to an underlying PFO. This report explores the factors that must be considered when making the decision to close the PFO and emphasizes the vital role of a multi-disciplinary team in determining the best course of action for patients with cryptogenic strokes.
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Affiliation(s)
- Noman Khalid
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | - Muhammad Abdullah
- Public Health & Community Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan Medical and Dental College, Shaikh Zayed Federal Postgraduate Medical Institute, Shaikh Zayed Medical Complex, Lahore, PAK
| | - Sacide S Ozgur
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | | | - Fayez Shamoon
- Cardiology, St. Joseph's Regional Medical Center, Paterson, USA
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Wang M, Lan D, Dandu C, Ding Y, Ji X, Meng R. Normobaric oxygen may attenuate the headache in patients with patent foramen povale and migraine. BMC Neurol 2023; 23:44. [PMID: 36707824 PMCID: PMC9881355 DOI: 10.1186/s12883-023-03059-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND PURPOSES There has been both great interest in and skepticism about the strategies for headache inhibition in patients with patent foramen ovale and migraines (PFO-migraine). Furthermore, many questions remain about the fundamental pathophysiology of PFO-migraines. Herein, the inhibiting effect of normobaric oxygenation (NBO) on PFO-migraine was analyzed. METHODS This real-world self-control study consecutively enrolled patients during the ictal phase of migraines who had patent foramen ovale (PFO) confirmed by Trans esophageal Ultrasound(TEE). After comparing the baseline arterial oxygen partial pressure (PaO2) in their blood gas with that of healthy volunteers, all the patients with PFO-migraine underwent treatment with NBO (8 L/min. for 1 h/q8h) inhalation through a mask. Their clinical symptoms, blood gas, and electroencephalograph (EEG) prior to and post-NBO were compared. RESULTS A total of 39 cases with PFO-migraine (in which 36% of participants only had a small-aperture of PFO) and 20 non-PFO volunteers entered the final analysis. Baseline blood gas analysis results showed that the PaO2 in patients with PFO-migraine were noticeably lower than PaO2 levels in non-PFO volunteers. After all patients with PFO-migraines underwent NBO treatment, 29(74.4%) of them demonstrated dramatic headache attenuation and a remarkable increase in their arterial PaO2 levels after one time treatment of NBO inhalation (p < 0.01). The arterial PaO2 levels in these patients gradually went down during the following 4 h after treatment. 5 patients finished their EEG scans prior to and post-NBO, and 4(80%) were found to have more abnormal slow waves in their baseline EEG maps. In the follow up EEG maps post-NBO treatment for these same 4 patients, the abnormal slow waves disappeared remarkably. CONCLUSIONS Patients with PFO-migraine may derive benefit from NBO treatment. PFOs result in arterial hypoxemia due to mixing of venous blood, which ultimately results in brain hypoxia and migraines. This series of events may be the key pathologic link explaining how PFOs lead to migraines. NBO use may attenuate the headaches from migraines by correcting the hypoxemia.
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Affiliation(s)
- Mengqi Wang
- grid.413259.80000 0004 0632 3337Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China ,grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China ,grid.413259.80000 0004 0632 3337National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
| | - Duo Lan
- grid.413259.80000 0004 0632 3337Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China ,grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China ,grid.413259.80000 0004 0632 3337National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
| | - Chaitu Dandu
- grid.254444.70000 0001 1456 7807Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201 USA
| | - Yuchuan Ding
- grid.254444.70000 0001 1456 7807Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI 48201 USA
| | - Xunming Ji
- grid.413259.80000 0004 0632 3337Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China ,grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China ,grid.413259.80000 0004 0632 3337National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
| | - Ran Meng
- grid.413259.80000 0004 0632 3337Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China ,grid.24696.3f0000 0004 0369 153XAdvanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, 100053 China ,grid.413259.80000 0004 0632 3337National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, 100053 China
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Zhu J, Chen A, Zhu L, Li Y, Tang Y, Huang Y, Shen H, Jiang Z, Liu X. Calf muscle pump tensing as a novel maneuver to improve the diagnostic performance of detecting patent foramen ovale during transesophageal echocardiography. Front Neurol 2023; 14:1116764. [PMID: 36761345 PMCID: PMC9905729 DOI: 10.3389/fneur.2023.1116764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023] Open
Abstract
Objective The Valsalva maneuver is the most sensitive provocative maneuver for patent foramen ovale detection. However, nearly half of patients are unable to perform the Valsalva maneuver well. The aim of this study was to investigate the mechanism of action of calf muscle pump tensing (TENSE) as a novel patent foramen ovale (PFO) provocative maneuver and to evaluate the diagnostic value for PFO and the effect on right-to-left shunt volume compared with the Valsalva maneuver. Methods This study prospectively investigated 171 patients who were highly suspected to have PFO clinically. Five patients with atrial septal defects newly diagnosed on transesophageal echocardiography (TEE) were excluded. 166 patients were injected with agitated saline under three provocative maneuvers: Valsalva maneuver, TENSE, and Valsalva + TENSE combined maneuver. The patients were divided into the effective Valsalva group (n = 93) and ineffective Valsalva group (n = 73) according to whether they could perform an effective Valsalva maneuver. TENSE consisted of the straightening of both lower limbs, and when the right atrium was filled with microbubbles, the patient performed instantaneous ankle dorsiflexion movements while maintaining dorsiflexion for 3-5 s. Results Overall, the PFO detection rate of the Valsalva + TENSE combined maneuver (78 [50.1%]) was significantly higher than that of the Valsalva maneuver (51 [30.7%]) and TENSE maneuver (57 [34.3%]) (P < 0.001). In the patients who were able to perform an effective Valsalva maneuver, the PFO detection rate by TENSE was not significantly different from that by the Valsalva maneuver (Valsalva 37/93 [39.8%] vs. TENSE 31/93 [33.3%], P > 0.05), while for the patients who performed an ineffective Valsalva maneuver, the PFO detection rate by the TENSE maneuver was higher than that by the Valsalva maneuver (TENSE 26/73 [35.6%] vs. Valsalva14/73[19.2%], P = 0.017). Conclusion TENSE is a simple and effective provocative maneuver in the diagnosis of PFO using TEE and can assist the Valsalva maneuver. For patients who cannot perform an effective Valsalva maneuver, TENSE can be an alternative to the Valsalva maneuver to some extent.
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Grosse GM, Leotescu A, Sieweke JT, Schneppenheim S, Budde U, Ziegler NL, Biber S, Gabriel MM, Ernst J, Schuppner R, Lichtinghagen R, Bavendiek U, Widder J, Weissenborn K. ADAMTS-13 activity in stroke of known and unknown cause: Relation to vascular risk factor burden. Front Neurol 2023; 13:1045478. [PMID: 36703637 PMCID: PMC9871749 DOI: 10.3389/fneur.2022.1045478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023] Open
Abstract
Background The identification of the underlying mechanism in ischemic stroke has important implications for secondary prevention. A disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS-13) has antithrombotic properties and was repeatedly implicated in the pathophysiology of stroke. In this study, we, therefore, aimed to investigate whether ADAMTS-13 is associated with stroke etiology and the burden of vascular risk factors. Methods We determined ADAMTS-13 activity in two prospectively recruited stroke cohorts in the long-term course after the event. Cohort 1 (n = 88) consisted of patients who suffered a stroke due to embolic stroke of undetermined source (ESUS), cardioembolic stroke due to atrial fibrillation (AF), large-artery atherosclerosis, or small vessel disease. In cohort 2, patients with cryptogenic stroke and patent foramen ovale (PFO) scheduled for PFO closure (n = 38) were enrolled. As measures of vascular risk factor burden, the CHA2DS2VASC score, the Essen Stroke Risk Score (ESRS), and the Risk of Paradoxical Embolism (RoPE) score were calculated, as appropriate. Results ADAMTS-13 activity was lower in patients with AF-related stroke compared to patients with ESUS (p = 0.0227), which was, however, due to confounding by vascular risk factors. ADAMTS-13 activity inversely correlated with the ESRS (r = -0.452, p < 0.001) and CHA2DS2VASC (r = -0.375, p < 0.001) in cohort 1. In accordance with these findings, we found a positive correlation between ADAMTS-13 activity and the RoPE score in cohort 2 (r = 0.413, p = 0.010). Conclusion ADAMTS-13 activity is inversely correlated with the number of vascular risk factors across different stroke etiologies. Further study is warranted to establish ADAMTS-13 as a mediator of cerebrovascular risk.
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Affiliation(s)
- Gerrit M. Grosse
- 1Department of Neurology, Hannover Medical School, Hannover, Germany,*Correspondence: Gerrit M. Grosse ✉
| | - Andrei Leotescu
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | | | | | - Ulrich Budde
- 3Medilys Laboratory, Asklepios Klinik Altona, Hamburg, Germany
| | - Nora L. Ziegler
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Saskia Biber
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Maria M. Gabriel
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Johanna Ernst
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ramona Schuppner
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Ralf Lichtinghagen
- 4Institute of Clinical Chemistry, Hannover Medical School, Hannover, Germany
| | - Udo Bavendiek
- 2Department of Cardiology, Hannover Medical School, Hannover, Germany
| | - Julian Widder
- 2Department of Cardiology, Hannover Medical School, Hannover, Germany,5Medizinische Klinik VI, Kardiologie, Angiologie und Internistische Intensivmedizin, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Karin Weissenborn
- 1Department of Neurology, Hannover Medical School, Hannover, Germany
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Shimfessel TT, El-Dalati SA, Sekela M, Ahmed T. Paradoxical embolisation in right-sided infective endocarditis and patent foramen ovale. BMJ Case Rep 2022; 15:e250272. [PMID: 35623657 PMCID: PMC9150164 DOI: 10.1136/bcr-2022-250272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 11/03/2022] Open
Abstract
Intravenous drug use (IVDU) is a growing public health crisis worldwide. A known complication of IVDU is right-sided infective endocarditis (RSIE) involving the tricuspid valve. As the tricuspid valve is burdened with infectious vegetations, it becomes a potential source of pulmonary and, very rarely, paradoxical systemic emboli. We report two patients with RSIE involving the tricuspid valve presenting with acute change in mental status. Subsequent imaging demonstrated embolisation to the brain in the setting of elevated right atrial pressures and the presence of a patent foramen ovale (PFO) with right-to-left shunting. We employed a strategy of percutaneous closure of PFO, to prevent further embolisation, as a successful bridge to definitive surgical management of RSIE. We emphasise that clinicians should evaluate for intracardiac shunting and pursue transesophageal echocardiography when encountering systemic emboli of unknown origin, particularly in patients with RSIE.
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Affiliation(s)
- Tyler T Shimfessel
- Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Sami A El-Dalati
- Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Michael Sekela
- Cardiothoracic Surgery, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Taha Ahmed
- Internal Medicine, University of Kentucky Medical Center, Lexington, Kentucky, USA
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