A Case of Pregnancy with a History of Paradoxical Brain Embolism

ABSTRACT

Brain embolisms in younger persons are rare but are often caused by a paradoxical embolism, the embolic entry of a venous thrombus into the systemic circulation through a right-to-left shunt. A 27-year-old pregnant woman presented with hemiplegia that had been treated with an antiplatelet agent since the occurrence of a paradoxical brain embolism via the pulmonary arteriovenous fistula. A tendency of hypercoagulation is generally observed during pregnancy, so a patient with this condition has a strong risk factor for venous thromboembolism during pregnancy and even more so for arterial thromboembolism under the intense strain of labor, which is much stronger than that of the Valsalva maneuver. This case had been controlled well with an antiplatelet agent and an anticoagulant while the levels of coagulation and fibrinolytic factors were monitored and was followed by a successful pregnancy outcome.

KEYWORD

Paradoxical embolism - brain embolism - pregnancy - transesophageal echocardiography (TEE) - transcranial Doppler (TCD)

REFERENCES

• 1 Sacco R K, Ellenberg J H, Mohr J P. Infarcts of undetermined cause: the NINCDS stroke data bank.  Ann Neurol . 1989;  25 382-390
• 2 Lechat P, Mas J L, Lascault G. Prevalence of patent foramen ovale in patients with stroke.  N Engl J Med . 1988;  318 1148-1152
• 3 François P, Fabre M, Lioret E. Vascular cerebral thrombosis during pregnancy and post-partum.  Neurochirurgie . 2000;  46 105-109
• 4 Kjeldsen A D, Andersen P E, Oxhøj H, Vase P. Embolisation of pulmonary arteriovenous malformations.  Ugeskr Laeger . 1998;  160 1465-1469
• 5 Loscaizo J. Paradoxical embolism: clinical presentation, diagnostic strategies, and therapeutic options.  Am Heart J . 1986;  112 141-145
• 6 Yonehara T, Sakamoto T, Matsuura D. Diagnostic criteria of paradoxycal brain embolism. Proceedings of the second meeting of the Japan Society of Embolus Detection and Treatment (Abst). Tokyo: Tokyo Women's Medical University 2001: 24
• 7 Kanda N, Yasaka M, Ohtsubo R. Right-to-left shunt and atrial septal aneurysm in stroke patients: a contrast transesophageal echocardiographic study.  Clin Neurol . 1998;  38 208-212
• 8 Meacham 3rd R R, Headley A S, Bronze M S. Impending paradoxical embolism.  Arch Intern Med . 1998;  158 438-448
• 9 Mas J L, Arquizan C, Lamy C. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both.  N Engl J Med . 2001;  345 1740-1746
• 10 Nemec J J, Marwick T H, Lorig R J. Comparison of transcranial Doppler ultrasound and transesophageal contrast echocardiography in the detection of interatrial right-to-left shunts.  Am J Cardiol . 1991;  68 1498-1502
• 11 Ringelstein E B, Droste D W, Babikian V L. Consensus on microembolus detection by TCD. International consensus group on microembolus detection.  Stroke . 1998;  29 725-729
• 12 Stöllberger C, Slany J, Schuster I. The prevalence of deep venous thrombosis in patients with suspected paradoxical embolism.  Ann Intern Med . 1993;  119 461-465
• 13 Harris E N, Gharavi A E, Hughes G RV. Anti-phospholipid antibodies.  Clin Rheum Dis . 1985;  11 591-609
• 14 Asherson R A. Antiphospholipid antibodies and syndromes. In: Lahita RG, ed. Systemic Lupus Erythematosus New York: Churchill Livingstone 1992: 587-635
• 15 Hirsh J, Fuster V. Guide to anticoagulant therapy. Part 1: Heparin.  Circulation . 1994;  89 1449-1468