Paradoxical Embolism Clinical Presentation

  • Author: Igor A Laskowski, MD; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: May 10, 2012
 

History

The clinical findings of paradoxical embolism (PDE) are nonspecific and are related to other disease entities such as pulmonary embolism (PE), neurologic deficits associated with transient ischemic attack (TIA) or embolic stroke, and systemic arterial embolism. The clinical triad of PDE consists of the following:

  • Deep vein thrombosis (DVT), with or without PE
  • Intracardiac communication with a right-to-left shunt
  • Arterial embolism

Patients with normal hemodynamics and a patent foramen ovale (PFO) show no detectable abnormality in their medical history or on physical examination, chest roentgenography, or electrocardiography (ECG); however, patients with right atrial pressure elevated above the left atrial pressure tend to have right-to-left shunts and a predisposition to PDE. A PFO is the most frequent conduit for right-to-left shunts.

Patient symptoms can be exacerbated with Valsalva-type maneuvers, such as defecation, urination, and cough. Despite provocative maneuvers (eg, Valsalva or cough), left atrial pressure may remain higher than right atrial pressure, thereby preventing right-to-left shunting.

PDE is increasingly recognized as a cause of embolic stroke.[6] It is often a diagnosis of exclusion. DVT as an initial source of PDE must be ruled out clinically. A causative relationship exists among DVT, PFO, and ischemic neurologic events. Neurologic deficits in patients with cardiovascular events or DVT, PE, or any unexplained arterial embolism (eg, in the retinal artery, mesenteric artery, splenic artery, or renal artery) should be regarded with a high level of clinical suspicion for PDE.[7]

Symptoms associated with DVT may include the following:

  • Unilateral leg pain
  • Leg swelling – Swelling of 1 lower extremity is the most important clinical manifestation of lower-extremity DVT; generally, the swelling is painless; on palpation, the calf muscle is tender, and the Homan sign is present in fewer than one half of DVT cases
  • Unilateral leg redness – Redness is not seen in most cases of DVT but is almost always seen in superficial thrombophlebitis
  • A positive history of previous DVT – This is indicative because one third of all DVTs are recurrent

Symptoms associated with PE include the following:

  • Dyspnea
  • Chest pain
  • Hemoptysis
  • Syncope

Symptoms associated with embolic stroke include the following:

  • Unilateral weakness
  • Speech abnormality
  • Visual abnormality
  • Swallowing abnormality
  • Seizures

Symptoms associated with arterial embolism depend on the affected artery, which can supply any of the extremities or any of the major organs. Symptoms include the following:

  • Acute severe extremity pain
  • In the classic case of embolic occlusion of a lower-extremity artery (eg, the femoral or popliteal artery), the clinical picture can be summarized as the 5 P s—that is, p ain, p allor, p ulselessness, p aresthesia, and p aralysis
  • Paresthesia
  • Numbness
  • Skin discoloration
  • Inability to use the extremity

The clinical symptoms associated with multiorgan arterial embolism depend on the location of the embolism (eg, the retinal artery, mesenteric artery, or splenic artery).

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Physical Examination

Physical manifestations of PDE are related to DVT, PE, and manifestations of peripheral or central arterial embolism.

DVT can present physically with the following:

  • Unilateral leg swelling, tenderness, warmth, and erythema
  • Palpable cord along the course of the affected veins (possible)
  • Appearance of prominent venous collaterals (may be noted)

PE may present physically with the following:

  • Tachypnea
  • Hypotension
  • Central cyanosis
  • Tachycardia
  • Low-grade fever
  • Jugular venous distention
  • Accentuated pulmonic component of the second heart sound
  • New-onset atrial fibrillation (sometimes a subtle sign of PE)

Physical manifestations of cerebral embolism include the following:

  • Focal neurologic deficits that correspond to the areas of the cerebral cortex supplied by the affected artery
  • Facial weakness and visual neglect
  • Broca or Wernicke aphasia

Physical manifestations of acute arterial occlusion depend on the site, duration, and severity of the obstruction. They may include the following:

  • Pain
  • Coldness
  • Paralysis or motor weakness
  • Peripheral cyanosis or pallor
  • Loss of sensation

Intracardiac clot can lead to a new murmur, depending on the size and the location.

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Complications

Complications of PDE include the following:

  • Neurologic deficit as a manifestation of stroke
  • Hemiplegia
  • Amaurosis fugax with eventual blindness
  • Motor aphasia
  • Seizure disorder complicating a cerebral insult
  • Arrhythmia, such as ventricular tachycardia or fibrillation (in cases of impending PDE)
  • Acute myocardial infarction (AMI)
  • Loss of limb function with amputation
  • Organ damage (eg, renal infarction)
  • Death
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Contributor Information and Disclosures
Author

Igor A Laskowski, MD  Assistant Professor of Surgery, Section of Vascular Surgery, New York Medical College, Westchester Medical Center

Igor A Laskowski, MD is a member of the following medical societies: American College of Surgeons, American Hepato-Pancreato-Biliary Association, Peripheral Vascular Surgery Society, Society for Vascular Surgery, and Transplantation Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sateesh C Babu, MD  Professor of Clinical Surgery, New York Medical College; Associate Director, Vascular Surgery, Co-chief Endovascular Surgery, Westchester Medical Center, Valhalla NY

Sateesh C Babu, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Institute of Ultrasound in Medicine, American Medical Association, Eastern Vascular Society, International Society of Endovascular Specialists, New York Academy of Sciences, Royal Society of Medicine, Society for Vascular Surgery, and Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Oladayo Adisa Osinuga Sr, MBBS  Attending Physician, Department of Internal Medicine, Atlanta Medical Center

Oladayo Adisa Osinuga Sr, MBBS is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Medical Association

Disclosure: Nothing to disclose.

Maurice Rachko  MD, Director of the Coronary Care Unit, Associate Director of the Chest Pain Unit, Beth Israel Medical Center

Maurice Rachko is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Klaus-Dieter Lessnau, MD, FCCP  Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital

Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Nelson S Menezes, MD, FRCS(Edin), FACS  Assistant Professor of Surgery, Weill Cornell Medical College; Chief of Vascular Surgery, Department of Surgery, Brooklyn Hospital Center

Nelson S Menezes, MD, FRCS(Edin), FACS is a member of the following medical societies: American College of Surgeons, International Society of Endovascular Specialists, Medical Society of the State of New York, and Society for Vascular Surgery

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center Program Director, Vascular Surgery Residency

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Additional Contributors

Steven J Compton, MD, FACC, FACP Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Alan D Forker, MD Professor of Medicine, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research, MidAmerica Heart Institute of St Luke's Hospital

Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa

Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

  1. Cohnheim J. Thrombose und Embolie. Vorlesung ueber allgemeine Pathologie. Berlin, Hirschwald. 1877;1:134.

  2. Wahl A, Jüni P, Mono ML, Kalesan B, Praz F, Geister L, et al. Long-term propensity score-matched comparison of percutaneous closure of patent foramen ovale with medical treatment after paradoxical embolism. Circulation. Feb 14 2012;125(6):803-12. [Medline].

  3. Eichhorn V, Bender A, Reuter DA. Paradoxical air embolism from a central venous catheter. Br J Anaesth. May 2009;102(5):717-8. [Medline].

  4. Vellayappan U, Attias MD, Shulman MS. Paradoxical embolization by amniotic fluid seen on the transesophageal echocardiography. Anesth Analg. Apr 2009;108(4):1110-2. [Medline].

  5. Mascarenhas V, Kalyanasundaram A, Nassef LA, Lico S, Qureshi A. Simultaneous massive pulmonary embolism and impending paradoxical embolism through a patent foramen ovale. J Am Coll Cardiol. Apr 14 2009;53(15):1338. [Medline].

  6. Nightingale S, Ray GS. Paradoxical embolism causing stroke and migraine. J Postgrad Med. Jul-Sep 2010;56(3):206-8. [Medline].

  7. Fischer D, Gardiwal A, Haentjes J, Klein G, Meyer GP, Drexler H, et al. Sustained risk of recurrent thromboembolic events in patients with patent foramen ovale and paradoxical embolism: long-term follow-up over more than 15 years. Clin Res Cardiol. Apr 2012;101(4):297-303. [Medline].

  8. Kuppuswamy M, Kourliouros A, Sutherland G, Sarsam M. Complete surgical correction for impending paradoxical embolism with pulmonary embolism, tricuspid regurgitation, and atrial flutter. Heart Surg Forum. Dec 2008;11(6):E378-9. [Medline].

  9. Cifarelli A, Musto C, Parma A, Pandolfi C, Pucci E, Fiorilli R, et al. Long-term outcome of transcatheter patent foramen ovale closure in patients with paradoxical embolism. Int J Cardiol. Jan 28 2009;[Medline].

  10. Allie DE, Lirtzman MD, Wyatt CH, et al. Septic paradoxical embolus through a patent foramen ovale after pacemaker implantation. Ann Thorac Surg. Mar 2000;69(3):946-8. [Medline].

  11. Bridges ND, Hellenbrand W, Latson L, et al. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation. Dec 1992;86(6):1902-8. [Medline].

  12. Cheng TO. Paradoxical embolism. Circulation. Jun 29 1999;99(25):3323. [Medline].

  13. Corrin C. Paradoxical embolism. Br Heart J. 1991;26:549.

  14. Dearani JA, Ugurlu BS, Danielson GK, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation. Nov 9 1999;100(19 Suppl):II171-5. [Medline].

  15. Devuyst G, Bogousslavsky J, Ruchat P, et al. Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology. Nov 1996;47(5):1162-6. [Medline].

  16. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. Jan 1984;59(1):17-20. [Medline].

  17. Hung J, Landzberg MJ, Jenkins KJ, et al. Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement. J Am Coll Cardiol. Apr 2000;35(5):1311-6. [Medline].

  18. Ikonomidis JS, Nisco SJ, Liang DH, et al. Paradoxical embolism of a shotgun pellet. Ann Thorac Surg. Aug 1998;66(2):562-4. [Medline].

  19. Johnson BI. Paradoxical embolism. J Clin Pathol. 1951;4:316-32.

  20. Kuhl HP, Hoffmann R, Merx MW, et al. Transthoracic echocardiography using second harmonic imaging: diagnostic alternative to transesophageal echocardiography for the detection of atrial right to left shunt in patients with cerebral embolic events. J Am Coll Cardiol. Nov 15 1999;34(6):1823-30. [Medline].

  21. Loscalzo J. Paradoxical embolism: clinical presentation, diagnostic strategies, and therapeutic options. Am Heart J. Jul 1986;112(1):141-5. [Medline].

  22. Lynch JJ, Schuchard GH, Gross CM, et al. Prevalence of right-to-left atrial shunting in a healthy population: detection by Valsalva maneuver contrast echocardiography. Am J Cardiol. May 15 1984;53(10):1478-80. [Medline].

  23. Mas JL. Diagnosis and management of paradoxical embolism and patent formen ovale. Curr Opin Cardiol. Sep 1996;11(5):519-24. [Medline].

  24. Mas JL, Zuber M. Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm. Am Heart J. Nov 1995;130(5):1083-8. [Medline].

  25. Meacham RR 3rd, Headley AS, Bronze MS, et al. Impending paradoxical embolism. Arch Intern Med. Mar 9 1998;158(5):438-48. [Medline].

  26. Nemec JJ, Marwick TH, Lorig RJ, et al. Comparison of transcranial Doppler ultrasound and transesophageal contrast echocardiography in the detection of interatrial right-to-left shunts. Am J Cardiol. Dec 1 1991;68(15):1498-502. [Medline].

  27. Sadanandan S, Sherrid MV. Clinical and echocardiographic characteristics of left atrial spontaneous echo contrast in sinus rhythm. J Am Coll Cardiol. Jun 2000;35(7):1932-1938. [Medline].

 
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