title: Acute stroke, catheter related venous thrombosis, and paradoxical cerebral embolism: report of two cases.
abstract: BACKGROUND
  Patent foramen ovale (PFO) has been associated with cryptogenic stroke, particularly in young adults. However, the source of particles leading to cerebral embolism remains frequently unknown despite comprehensive evaluation.
  
  
  OBJECTIVE
  To report and comment on therapeutic options for 2 patients with acute ischemic strokes, PFO, and venous access related thrombosis, sources of paradoxical embolism, from Boston Medical Center stroke database.
  
  
  METHODS
  Case 1. A 71-year-old man presented with brain magnetic resonance imaging (MRI) confirmed acute cerebellar infarction. Echocardiography showed a PFO and thrombotic material at the tip of a peripherally inserted central catheter (PICC) line in the superior vena cava (SVC) prolapsing into the right atrium (RA). Case 2. A 64-year-old woman with end-stage renal disease and PFO presented with brain MRI confirmed acute parietal lobe infarction. Three days prior to her stroke, she had thrombectomy and venoplasty of an arterio-venous (AV) dialysis graft followed by a post-thrombectomy fistulogram that showed persistent thrombotic material at the venous site.
  
  
  CONCLUSIONS
  PFO associated with large venous access site thrombosis was the most likely mechanism of stroke in both cases. Local thrombosis at sites of large venous access may be an overlooked source of paradoxical embolism in patients with PFO as well as a preventable cause of stroke in critically ill patients.
authors.affiliation: From the Department of Neurology, University of Kentucky College of Medicine, Lexington, KY 40536-0284, USA. rodica.petrea@uky.edu
authors.forename: Rodica Elena
authors.initials: RE
authors.lastname: Petrea
authors.forename: Feliks
authors.initials: F
authors.lastname: Koyfman
authors.forename: Aleksandra
authors.initials: A
authors.lastname: Pikula
authors.forename: Jose Rafael
authors.initials: JR
authors.lastname: Romero
authors.forename: Jason
authors.initials: J
authors.lastname: Viereck
authors.forename: Viken L
authors.initials: VL
authors.lastname: Babikian
authors.forename: Carlos S
authors.initials: CS
authors.lastname: Kase
authors.forename: Thanh N
authors.initials: TN
authors.lastname: Nguyen
mesh_terms: D000368:Aged; D019320:Embolism, Paradoxical / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications* / Q000175:diagnosis / Q000601:surgery; D006801:Humans; D020766:Intracranial Embolism / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D056824:Upper Extremity Deep Vein Thrombosis / Q000150:complications* / Q000175:diagnosis / Q000601:surgery