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. 2018 Nov 15:6:2324709618813175.
doi: 10.1177/2324709618813175. eCollection 2018 Jan-Dec.

Iatrogenic Paradoxical Stroke in a Patient With Catheter-Associated Thrombosis and Systemic-to-Pulmonary Venous Shunt

Lucas J Policastro  1 , Kristaq Koci  1
Affiliations

Iatrogenic Paradoxical Stroke in a Patient With Catheter-Associated Thrombosis and Systemic-to-Pulmonary Venous Shunt

Lucas J Policastro et al. J Investig Med High Impact Case Rep. .

Abstract

Paradoxical embolism occurs when thrombotic material traverses a right-to-left shunt. We describe the first case of paradoxical stroke resulting from manipulation of a disused chemotherapy port. Contrast studies revealed that the mechanism was systemic-to-pulmonary venous shunt, in which systemic veins drain into the left atrium via collaterals. Chronically thrombosed central venous catheters may result in venous stenosis and shunt formation, exposing patients to risks of paradoxical stroke, acute coronary syndrome, hypoxemia, and other complications. This case highlights the life-threatening complications that may result from neglect of an implantable central venous catheter. Preventative measures are to promptly recognize and treat catheter-related thrombosis and to remove unneeded catheters.

Keywords: central venous access device; paradoxical embolism; paradoxical stroke; right-to-left shunt; systemic-to-pulmonary venous shunt.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Magnetic resonance imaging demonstrating acute ischemic stroke. Left, T2 FLAIR image showing a high signal lesion in the right frontal lobe. Center and right, diffusion-weighted images showing bilateral positive gyriform signals in the right and left posterior frontal lobes.
Figure 2.
Figure 2.
Chest computed tomography angiogram conducted under pulmonary embolism protocol. Contrast was injected into a left upper extremity vein. (a) Venous collaterals are well-developed as a result of left brachiocephalic vein stenosis. (b) Contrast is seen within the left superior pulmonary vein (arrow). (c) Four coronal slices are shown, demonstrating collateralization of the left bronchial venous plexus as well as enhancement of the left pulmonary vein.
Figure 3.
Figure 3.
Digital subtraction venogram demonstrating collateral flow from the left upper extremity. The accessory hemiazygos vein (white arrow) has become a prominent collateral of the left subclavian. Flow is reversed within the left bronchial veins (black arrow), seen receiving blood from the accessory hemiazygos vein and/or left superior intercostal vein. As a result, the left bronchial venous plexus is filled with contrast (yellow-dashed arrow). This plexus drains to the pulmonary veins.
Figure 4.
Figure 4.
A schematic of the collateral venous flow in systemic-to-pulmonary venous shunt via the left bronchial veins.
See this image and copyright information in PMC

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