Images in Cardiovascular Medicine
Popliteal Venous Aneurysm With Paradoxical Embolization
in a Patient With Patent Foramen Ovale
W.A. Willinek, MD; H. Strunk, MD; M. Born, MD; J. Remig, MD; H. Becher, MD; H. Schild, MD

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n 18-year-old woman was found in bed with right-sided
hemiplegia and global aphasia. Acute ischemic lesions
in the left basal ganglia, the left insula cortex, and the cortex
of the left parietal lobe were found on diffusion-weighted
MRI (Figure 1). The patient underwent contrast echography,
and a patent foramen ovale with right-to-left shunt was
diagnosed (Figure 2). Systemic anticoagulation with heparin
was initiated, and a regression of neurological signs and
symptoms was observed. Comorbid diseases such as a coagulation disorder, a thrombus within a cardiac chamber, and

cerebral or carotid atherosclerosis were excluded. A duplex
scan revealed a 3.5⫻4 cm saccular popliteal venous aneurysm (Figure 3), which was confirmed by MRI and was
presumed to be the origin of paradoxical embolization. The
patient underwent tangential aneurysmectomy and lateral
venorrhaphy of a 4⫻3.5⫻2.5 cm saccular venous aneurysm.
No thrombus was noted within the aneurysm. In a second
session, transcatheter closure of the foramen ovale with an
umbrella system was performed. The patient tolerated both
procedures well and has remained symptom-free.

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Figure 2. Contrast echocardiographic examination. Contrast
material completely fills the right atrium and appears in the left
atrium through a patent foramen ovale (arrow). RA indicates
right atrium; LA, left atrium.

Figure 1. Axial diffusion-weighted MRI of the brain performed on the
day of admission. Diffusion-weighted imaging showed fresh infarction
of the left basal ganglia, left insula, and parietal lobe cortex.

From the Departments of Radiology (W.A.W., H.S., M.B., H.S.), Surgery (J.R.), and Cardiology (H.B.), University of Bonn, Bonn, Germany.
Correspondence to Dr W.A. Willinek, Department of Radiology, University of Bonn, Sigmund-Freud-Str 25, D-53105 Bonn, Germany. E-mail
willinek@uni-bonn.de
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and
Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute,
6720 Bertner Ave, MC1-267, Houston, TX 77030.
(Circulation. 2001;104:e60-e61.)
© 2001 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org

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Circulation

September 18, 2001

Figure 3. Duplex sonography of the left popliteal venous aneurysm with the patient in upright position. Extremely slow flow
was demonstrated within the lumen of the aneurysm.

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