A Case of Paradoxical Cerebral Embolism and Ischemic Stroke after Local Thrombolysis for Deep Vein Thrombosis

Case: A 68-year-old woman presented to our emergency room with subjective fevers, non-productive cough and severe pain in the right lower extremity. Of note, she had sustained a right patellar fracture 6 weeks earlier, treated with a brace. Physical examination showed right lower extremity swelling. Subsequently, she was diagnosed with extensive right deep venous thrombosis (DVT). Local thrombolysis of the DVT was achieved by injecting tissue plasminogen activator (tpa) followed by mechanical aspiration. Immediately post procedure; the patient experienced an acute deterioration in her mental status with left hemiparesis. CT angiography of the head confirmed a right middle cerebral artery (MCA) ischemic stroke. Successful reperfusion was achieved by performing an emergent embolectomy in the M1 branch of the MCA. A bubble contrast transthoracic echocardiogram showed a patent foramen ovale (PFO). The patient’s neurological symptoms gradually improved and at 6 month follow up she had no focal neurological deficits. Discussion: We describe the first case of an embolic stroke complicating catheter directed thrombolysis (CDT) for DVT in patient with elevated pulmonary arterial pressure as a result of acute pulmonary emboli. Currently there are no guidelines mandating routine checks for PFOs prior to performing CDT. This case illustrates the need for high clinical vigilance for PFO in patients being evaluated for CDT and provides a unique insight into a rare complication.