Paradoxical Embolism Differential Diagnoses

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

Diagnostic Considerations

Paradoxical embolism (PDE) is a diagnosis of exclusion. It is easily mimicked by other diseases causing cerebral and peripheral arterial embolism. The major difference is that thrombus forms on the left side of the heart, including the atrial or ventricular wall and the mitral or aortic valve. The arterial embolism may lead to permanent damage, resulting in stroke, infarction of organs, or gangrene of extremities (commonly the lower extremities).

Cardioembolism causes approximately 15% of all strokes.

PDE plays a causative role in the etiology of cerebral embolism; other causes include atrial fibrillation, ischemic cardiomyopathy, myocardial infarction (MI), mitral stenosis with or without atrial fibrillation, prosthetic valves, septic endocarditis, atrial myxoma, fat emboli, septal aneurysm, and ascending aortic atherosclerosis.

Peripheral arterial embolism from PDE must be differentiated from embolism of unknown origin. PDE may be associated with a hypercoagulable state, carcinoma (eg, of the pancreas), factor C or S deficiency, factor V Leiden (resistance to activated protein C), and prothrombin mutations. Atherothrombotic arterial manifestations may be difficult to differentiate in the process of trying to rule out the source of the embolus.

The arterial embolism may fragment or lyse, and the circulation may be restored over a period of time or immediately, mimicking a transient ischemic attack (TIA) from a different source. TIA may be a warning sign of eventual permanent neurologic damage.

Current diagnosis of PDE requires the following criteria:

  • Deep vein thrombosis (DVT), with or without pulmonary embolism (PE)
  • Abnormal communication between the right (venous) and left (systemic) sides of the circulatory system
  • Clinical, angiographic, or pathologic evidence of systemic embolism
  • Presence of a favorable pressure gradient, promoting right-to-left shunting

When a patent foramen ovale (PFO) is detected in a patient with embolism, leg DVT is present in approximately 90%. DVT may be occult upon physical examination.

Because PDE is a diagnostic challenge that is prone to misdiagnosis, medicolegal action by the patient and family may result. To avoid unwanted medicolegal implications, the index of suspicion for PDE should be high.

Differential Diagnoses

  • Deep Venous Thrombosis
Proceed to Workup
 
 
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

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