A Case of Cryptogenic Stroke Associated with Patent Foramen Ovale Coexisting with Pulmonary Embolisms, Deep Vein Thromboses, and Renal Artery Infarctions
A 52-year-old woman was transferred to our emergency room (ER) with a 10-hour history of left-side weakness, and a sudden onset of slurred speech, with a clear mental state. Her previous medical, medication, and familial histories were unremarkable, and she was a non-smoker. Upon arrival in the ER, she was hemodynamically stable and her electrocardiogram showed a normal sinus rhythm. However, a magnetic resonance diffusion image of her brain revealed an infarction of the right middle cerebral artery territory (), and a magnetic resonance angiogram of the cerebral and carotid arteries showed a total obstruction of the genu branch of the right middle cerebral artery (). She was immediately admitted to the neurologic intensive care unit, with a diagnosis of acute cerebral infarction. Further studies were then ordered, since the etiology of the cerebral infarction was unclear. To evaluate the intracardiac source of the embolism, a transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) were performed after 1 week. The TTE revealed no evidence of embolism; however, the TEE revealed separation of the septum primum from the septum secundum that constitutes a PFO, up to 6 mm, according to the pressure variance (), and an agitated saline injection test was used to identify the right-to-left microbubble shunting, during a Valsalva maneuver used to confirm the PFO presence (). Based on these tests, we subsequently recommended an anticoagulation therapy based on warfarinization.\nThe day after these initial tests, the patient complained of severe dyspnea and chest tightness, while walking. She then displayed severe hypoxemia and hypotension, and was immediately intubated and initiated the ventilator care. A computed tomography (CT) image of her chest was taken after starting the ventilator care, which showed massive thromboembolisms in the right pulmonary artery and left pulmonary segmental artery (), indicating an acute PTE. Because she was in a hemodynamically compromised state, we considered the use of thrombolytic therapy, in spite of the general contraindication of a recent cerebral infarction. After the discussion with a neurologist, we decided to treat her with a half dosage of recombinant tissue plasminogen activator {rtPA, Actylase® (Boehringer Ingelheim, Ingelheim, Germany); 45 mg total} in order to treat the massive PTE. Within 2-3 hours after an intravenous infusion of the thrombolytic agent, hypoxemia and hypotension symptoms returned to a normal state. After stabilization of her vital signs, we checked for the presence of DVT; the CT venogram of her lower extremities showed thrombi on her left iliac vein and both peroneal veins (). On the arterial phase of this CT, previous thrombi in the right main pulmonary and left segmental arteries were resolved (). In addition, there were newly developed multiple wedge-shaped hypoperfusion lesions in both kidneys, compatible with an acute renal infarction (). A work-up of vasculopathies, hypercoagulable states, and hematologic disorders proved unremarkable. We, subsequently, started an oral anticoagulation therapy with warfarin potassium. As a result of this treatment plan, the patient was discharged 20 days after admission, and has since been visiting the out-patient department on a regular basis without recurrence of these ischemic events.