title: Superior vena cava thrombosis and paradoxical embolic stroke due to collateral drainage from the brachiocephalic vein to the left atrium.
abstract: Thrombosis involving a permanent infusion catheter in the subclavian vein and superior vena cava is relatively common, especially in cancer patients. Edema of the arms and head is a well-known clinical consequence of this thrombosis, with an intrinsic risk of pulmonary embolism; however, systemic embolization into the cerebral circulation has not been reported as a sequela. Herein, we describe the case of a 56-year-old man with metastatic prostate cancer who developed superior vena cava syndrome due to extensive thrombosis in the presence of a central venous catheter that was used for long-term chemotherapy. The patient's case was complicated by a cerebrovascular accident that was most likely caused by a paradoxical air embolism. A clear mechanism for the embolism was provided by a network of collateral veins, which developed between the brachiocephalic vein and the left atrium due to the superior vena cava obstruction and resulted in a right-to-left shunt. We discuss diagnosis and treatment of the condition in our patient and in general terms.
authors.affiliation: Department of Cardiology, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas 77030, USA.
authors.forename: Angelo
authors.initials: A
authors.lastname: Nascimbene
authors.forename: Paolo
authors.initials: P
authors.lastname: Angelini
mesh_terms: D000970:Antineoplastic Agents / Q000008:administration & dosage; D016121:Brachiocephalic Veins / Q000000981:diagnostic imaging / Q000503:physiopathology*; D002404:Catheterization / Q000295:instrumentation; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation; D002408:Catheters, Indwelling / Q000009:adverse effects*; D003097:Collateral Circulation; D020878:Device Removal; D017548:Echocardiography, Transesophageal; D019320:Embolism, Paradoxical / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D006325:Heart Atria / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D011471:Prostatic Neoplasms / Q000188:drug therapy / Q000556:secondary; D015607:Stents; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D013479:Superior Vena Cava Syndrome / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents