Coles Anna, Haveman-Gould Bradley, Farooq Muhammad U, Selke Kristopher J, Gorelick Philip B
College of Human Medicine, Michigan State University, Grand Rapids, MI, USA.
Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, Grand Rapids, MI, USA.
Neurohospitalist. 2016 Jul;6(3):114-7. doi: 10.1177/1941874415588750. Epub 2015 Jun 2.
Patent foramen ovale (PFO) has been proposed as a mechanism for cardioembolic stroke, especially in younger patient populations. Complex PFOs, with tunnel lengths exceeding 8 mm, lead to a higher risk of neurological sequelae than simple PFOs and may also be harder to detect with transthoracic echocardiography (TTE). In this article, we present a 29-year-old woman who, after polypharmacy overdose, developed deep venous thrombosis and multiple pulmonary emboli (PE) and subsequent cardioembolic stroke. Initial TTE showed intact interatrial septum with late appearance of agitated saline in the left atrium after the seventh cardiac cycle. Subsequent transesophageal echocardiography, after treatment of PE with an intravenous thrombolytic (alteplase) and anticoagulation with heparin, showed a complex PFO with a 19-mm overlap of the septum primum and secundum without active flow. It is suggested that this PFO allowed for flow only in the situation of elevated right heart strain with PE, causing cardioembolic stroke and detection of agitated saline in the left atrium on TTE. However, under normal physiological situations, which resumed after treatment of PE with alteplase and heparin, the PFO did not allow for flow. This case demonstrates the potential importance of recognition of complex PFOs in diagnosis and management of cardioembolic stroke.
卵圆孔未闭（PFO）已被提出作为心源性栓塞性卒中的一种机制，尤其是在年轻患者群体中。隧道长度超过8mm的复杂型PFO比简单型PFO导致神经后遗症的风险更高，并且经胸超声心动图（TTE）可能也更难检测到。在本文中，我们介绍了一名29岁的女性，在过量服用多种药物后，发生了深静脉血栓形成和多发性肺栓塞（PE），随后出现了心源性栓塞性卒中。初始TTE显示房间隔完整，在第七个心动周期后左心房出现延迟显影的搅动盐水。在使用静脉溶栓药物（阿替普酶）治疗PE并使用肝素抗凝后，随后的经食管超声心动图显示存在一个复杂型PFO，原发隔和继发隔重叠19mm，无活动性血流。提示该PFO仅在PE导致右心压力升高的情况下允许血流通过，从而引起心源性栓塞性卒中以及TTE检查时左心房出现搅动盐水显影。然而，在用阿替普酶和肝素治疗PE后恢复的正常生理情况下，该PFO不允许血流通过。本病例证明了识别复杂型PFO在诊断和管理心源性栓塞性卒中方面的潜在重要性。
