Patent Foramen Ovale? An Interesting Case Report

Introduction.Patent foramina ovalia (PFOs) are found in 25% of adult population. 1 The prevalence of PFOs in cryptogenic strokes is higher than in those of known causes, 2 and because strokes caused by paradoxical emboli are multifactorial, they are under-reported.This case describes a stroke caused by a peripherally inserted central catheter (PICC)-associated thrombus resulting in a paradoxical embolism via a PFO.Case Report.A 41-year-old male was found with a pericardial effusion.A PICC line was placed following admission.He underwent an emergent pericardial window with 2 L of purulent drainage removed.On POD 5, he developed dysarthria, right hemisensory loss, and hemiparesis.A CT head was normal, but a CT angiography head/neck showed left PCA occlusion, and he was taken for thrombectomy.He had successful clot extirpation and recanalization.A transesophageal echocardiogram (TEE) showed a right atrial mass measuring 1-1.5 x 2 cm.The PICC line was noted to "intermittently touch" the mass with each heartbeat.Additionally, there was a small PFO with right-to-left shunting.The PICC line was removed, and a heparin infusion was started.Removal of the mass surgically or intravascularly was discussed.A few days later, a repeat TEE showed the thrombus had decreased in size.The patient opted to transition to oral anticoagulation and to consider outpatient PFO closure.He had complete resolution of his neurological symptoms.Discussion.The prevalence of PFOs, and their correlation with cryptogenic strokes, mandates a careful clinical approach when choosing to place central catheters, which carry a known risk of thrombosis. 3