Stroke due to paradoxical embolism in Ebstein’s anomaly

摘要

A 28-year-old woman, without past medical history or cardiovascularrisk factors, presented to the emergency department with suddenonset of left-sided hemiplegia and dysarthria during straining on thetoilet. Intracranial computed tomography angiography revealedan occlusion of the M1 branch of the right middle cerebral artery(Panel A). She received intravenous thrombolysis with full neurologicalrecovery. The cardiologist was consulted because of this youngstroke. The electrocardiogram showed sinus rhythm with a PR intervalof 206 ms and a right bundle branch block (Panel B). Ambulatoryrhythm monitoring showed no abnormalities. Patient underwenttransthoracic echocardiography revealing an Ebstein’s anomaly with alarge right atrium, due to atrialization of the right ventricle and apicaldisplacement of the septal leaflet insertion of the tricuspid valve.There also was pronounced redundancy of the leaflet with a possiblethrombus (Panels C and D, Supplementary material online, Videos S1and S2). Subsequent transoesophageal echocardiogram showed apatent foramen ovale (PFO) with right-to-left shunting of agitatedsaline at rest (Panel E, Supplementary material online, Video S3).Doppler ultrasonogram of lower extremities revealed no deepvenous thrombosis. Anti-coagulation was initiated and the patientwas referred and accepted to a congenital heart disease centrefor closure of the PFO. The treatment was in line with the Europeanposition paper on the management of patients with PFO. Though,because of a possible right atrial thrombus, the closure of the PFO ispostponed for at least 3 months and a control echocardiogram willbe performed.