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학회지

Journal of Neurosonology 2011; 3 ( Suppl. 2) : 65-65

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A case of recurrent ischemic stroke due to paradoxical embolism through different channels
  • Dong-geun Lee, MD, Seungyoo Kim, MD, Jae Young An, MD, Sung Kyung Park, MD, Si-Ryung Han, MD, PhD
  • Department of Neurology, St. Vincent's Hospital, The Catholic University of Korea

A case of recurrent ischemic stroke due to paradoxical embolism through different channels
  • Dong-geun Lee, MD, Seungyoo Kim, MD, Jae Young An, MD, Sung Kyung Park, MD, Si-Ryung Han, MD, PhD
  • Department of Neurology, St. Vincent's Hospital, The Catholic University of Korea
In evaluating an ischemic stroke, we should think of other causes, such as cardioembolism, vasculitis or paradoxical embolism, if there were no vascular risk factors or vasculopathy. We report a patient of recurrent ischemic strokes possibly due to paradoxical embolism through different channels. A 37 year old female was admitted because of headache, dizziness, nausea and vomiting had started abruptly. She had no vascular risk factors such as, hypertension, diabetes, cigarette smoking, physical inactivity, dyslipidemia and obesity. Neurological examination revealed non-specific except the tendency of swaying to left side during tandem gait. Magnetic resonance image revealed high signal intensity (SI) change on left posterior inferior cerebellar arterial (PICA) territory of cerebellum on T2 weighted image and diffusion weighted images (DWI). Magnetic resonance angiography (MRA) showed no sign of atherosclerosis, dissection, aneurysm, or stenosis. Examinations to rule out cardioembolism such as, electrocardiogram, 24 hour Holter monitoring, trans-thoracic echocardiogram (TTE) resulted in normal. But on transcranial Doppler (TCD) sonography, there were multiple microembolic signals (MES) during agitated saline test. Trans-esophageal echocardiogram (TEE) revealed patent foramen ovale (PFO). We started anticoagulation for secondary prevention. 2 months later, surgical correction of PFO was done. On operation field, 0.5 cm × 0.5 cm sized PFO was observed after right atriotomy, and it was directly closed by 5-0 prolene suture. She discharged without any complication. 11 months later after PFO closure, the patient was admitted again. At that time she complained of dizziness. DWI revealed high SI in the right PICA territory of right cerebellum. MRA revealed no arteriopathy again. On TCD, there were multiple MES during valsalva maneuver again, but on TEE, there was no sign of agitated saline leakage through PFO closure site. We thought that there could be another channel of paradoxical embolization. We did computed tomography (CT) on chest, and it revealed an engorged pulmonary vessels at anterior basal segment of right lower lobe, suggestive of pulmonary arterio-venous malformation (AVM) draining into the right lower pulmonary vein. Pulmonary angiography confirmed of AVM and embolization with coil was done in endovascular manner. We observed the patient for 18 months, and no cerebrovascular accident was recurred, ever after.