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Acute Lethal Stroke Affecting All Brain-Supplying Cerebral Arteries due to Paradoxical Embolism through a Patent Foramen ovale

A 26-year-old woman with a history of optic nerve atrophy of unknown origin was found unresponsive in the bathroom leading to an emergency admission in the local district hospital. CCT (fig. 1) revealed slight hypodensity according to the left posterior cerebral artery prompting transfer to our neurological department. On admission the patient was comatose with flexing of all extremities after painful stimuli. The right pupil was large and not reactive. The left eye had been treated operatively because of optic nerve atrophy of unknown origin. The corneal reflex was regular. The eyeballs were slightly divergent. The remaining brainstem reflexes were intact. Deep tendon reflexes were symmetrically and plantar reflexes bilaterally extensor. The patient was cardiopulmonarily stable and mechanically ventilated. A thrombosis of the basilar artery was suspected and emergency angiography performed. On the right side an occlusion of the internal carotid artery (fig. 2a) and the subclavian artery (fig. 2b) was found. The basilar artery was occluded slightly distal to the branches of the superior cerebellar artery (fig. 2c), and the left internal carotid artery was strongly stenosed (fig. 2d). The aortic arch was regular without signs of aortic dissection. Despite efforts with all available methods of neurological critical care, the patient rapidly deteriorated with successive loss of brainstem reflexes to clinical and EEG-documented brain death. Autopsy revealed a fulminant thromboembolic disease with pulmonary embolism, consecutive right heart dilatation and severe paradoxical embolism via a 10-mm diameter large patent foramen ovale. The large vessel did not show vasculitic or atherosclerotic changes. No transesophageal echocardiography or contrast transcranial Doppler sonography were performed in the past [1, 2]. We strongly believe that the lethal stroke in our patient was caused by acute paradoxical embolism. The embolic material probably traversed from the right heart to the left heart via the patent foramen ovale. The right vessels originating from the aortic arch were more affected, probably because the blood stream from the aorta goes to the right brachiocephalic trunk first. In conclusion, stroke due to paradoxical embolism via a patent foramen ovale can be lethal as it was in our patient.