PMC7640599_01
(A) Cranial computed tomography at presentation and (B) cranial magnetic resonance after 5 days since admission. No acute hemorrhagic lesions were observed (A). Multiple punctate foci in both hemispheres (white arrows) suggest embolism from a proximal source (B).
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A cranial computed tomography was performed (Fig. 1A), and no acute hemorrhagic lesions were found; therefore, the patient was admitted to the neurology department with the diagnosis of ischemic stroke. Subsequently, a cranial magnetic resonance imaging was performed, which demonstrated multiple punctate foci in both hemispheres, suggesting embolism from a proximal source (Fig. 1B).
Transthoracic echocardiogram: (A) four-chamber view and (B) two-chamber view (B). Large serpiginous structure in the right atrium extending to the left atrium and passing through the mitral valve (white arrows).
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However, a large serpiginous structure in the right atrium extending to the left atrium and passing through mitral valve was observed (Fig. 2), which was moving along the left ventricular outflow tract during systole and through the mitral annulus in diastole.
Transesophageal echocardiography (TEE) and 3D-TEE. A large mass consistent with thrombus coming from the inferior vena cava and passing through a patent foramen ovale to the left atrium and left ventricle.
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The study was completed with a trans-esophageal echocardiogram (TEE) that showed a large mass consistent with thrombus coming from the inferior vena cava and passing through a PFO to the left atrium and the left ventricle (Fig. 3).
Emergent surgical procedure. Surgical cardiac thrombectomy with closure of the patent foramen ovale was performed without complications.
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Because of the high suspicion of a thrombus in transit through a PFO associated with paradoxical embolism and the extreme risk of recurrent systemic and pulmonary embolism, the patient was taken urgently to the operating room, and cardiac thrombectomy with closure of the PFO was performed without complications (Fig. 4).