YAJEM-57526; No of Pages 2 American Journal of Emergency Medicine xxx (2018) xxx–xxx Contents lists available at ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Paradoxical brain embolism shadowing massive pulmonary embolism François Bagate, MD ⁎, Alexandre Bedet, MD, Armand Mekontso Dessap, MD, PhD, Guillaume Carteaux, MD, PhD AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Réanimation Médicale, Créteil, F-94010, France Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, F-94010, France a r t i c l e i n f o Article history: Received 2 February 2018 Received in revised form 7 May 2018 Accepted 13 May 2018 Available online xxxx a b s t r a c t Patent foramen ovale is frequently observed in the general population. In case of massive pulmonary embolism, the sudden increase in the right heart cavity's pressure may cause a right-to-left shunting across this foramen, which could be associated with conflicting outcomes. Herein, we report a case of reversible cardiac arrest preceded by seizures, and followed by hemodynamic stability without any vasopressor. A brain CT-scan showed a limited ischemic stroke. Initial echocardiographic assessment revealed an acute cor pulmonale and a right-toleft intracardiac shunt across a large patent foramen ovale, suggesting the diagnosis of massive pulmonary embolism that was lately confirmed by a multidetector CT-angiography. Anticoagulation therapy was rapidly complicated by a hemorrhagic transformation of the ischemic stroke leading to a fatal outcome. This case illustrates the double-edged circulatory effect of shunting across a patent foramen ovale in case of massive pulmonary embolism: it may have limited circulatory failure but caused in the meanwhile a fatal paradoxical brain embolism. © 2018 Elsevier Inc. All rights reserved. A 44-year old man recently hospitalized for a psychiatric disorder without other medical history, was referred to the ICU for a nonshockable cardiac arrest preceded by seizure. The spontaneous circulation was resumed 15 min after initial cardiopulmonary resuscitation, with no hemodynamic instability, but a persistent impaired consciousness prompting to endotracheal intubation. A brain computed tomography (CT) scan was performed first before ICU admission and revealed a low-density area into the left parietal lobe, compatible with an ischemic stroke (Fig. 1a). Upon ICU admission, transthoracic echocardiography (TTE) disclosed an acute cor pulmonale (Fig. 1b and Supplemental videos 1 and 2). Contrast-enhanced TTE (sub-costal view), using a modified fluid gelatin solution (9 mL of gelofusine agitated with 1 mL of room air) to make the right heart chambers opaque [1], evidenced a right-to-left intracardiac shunt across a large patent foramen ovale (Supplemental video 3). Multidetector CT-angiography revealed a bilateral pulmonary embolism (Fig. 1c). Parenteral anticoagulation with unfractionated heparin was introduced. No thrombolytic treatment was administered. On day-1, unilateral mydriasis arose, rapidly followed by progressive disappearance of brainstem reflexes. A second brain CT scan showed a hemorrhagic transformation of the ischemic ⁎ Corresponding author at: Hôpitaux de Paris, Groupe Henri Mondor-Albert Chenevier, Service de Réanimation Médicale, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil Cedex, France. E-mail address: francois.bagate@aphp.fr (F. Bagate). stroke with cerebral edema, responsible for brainstem compression (Fig. 1d). Brain death was diagnosed a few hours later. Patent foramen ovale is common, occurring in up to one quarter of the population [2]. In case of massive pulmonary embolism, a variable level of shunt across the foramen ovale frequently arises [3,4], due to the increase in right heart cavity's pressures. The presence of patent foramen ovale and its resulting right-to-left intracardiac shunt during massive pulmonary embolism is associated with conflicting outcomes; protective when shunting prevent fatal obstructive shock [5]; or deleterious when shunting worsens hypoxemia or allows paradoxical embolism [3,4]. Paradoxical embolism is a dreaded complication [6] of pulmonary embolism that was first described in the 19th century [7]. The possible protective effect of shunting across a patent foramen ovale during massive pulmonary embolism remains controversial [5,8,9]. Nevertheless, systematic realization of contrast-enhanced TTE at initial assessment during massive pulmonary embolism could be proposed in order to search for a patent foramen ovale and therefore anticipate its potential consequences. This case illustrates the double-edged circulatory effect of shunting across patent foramen ovale in case of massive pulmonary embolism. In fact, the intra-cardiac shunt has presumably favored the return of spontaneous circulation and limited circulatory insufficiency after resuscitation. On the other hand, it led in the meantime to a fatal paradoxical brain embolism. Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2018.05.024. https://doi.org/10.1016/j.ajem.2018.05.024 0735-6757/© 2018 Elsevier Inc. All rights reserved. Please cite this article as: Bagate F, et al, Paradoxical brain embolism shadowing massive pulmonary embolism, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.05.024 2 F. Bagate et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx Fig. 1. a Initial brain CT-scan revealed an acute ischemic stroke in the posterior cerebral artery territory (black arrowhead). b Transthoracic echocardiography (four-chamber view) highlighted a massive acute cor pulmonale with severe dilation of the right ventricle (RV) compared to the left ventricle (LV). c Thoracic CT scan showed bilateral segmental pulmonary embolism (white arrowheads). d Second brain CT-scan exhibited hemorrhagic transformation of the ischemic stroke. References [1] Silvestry FE, Cohen MS, Armsby LB, Burkule NJ, Fleishman CE, Hijazi ZM, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr 2015;28:910–58. [2] Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20. [3] Kasper W, Geibel A, Tiede N, Just H. Patent foramen ovale in patients with haemodynamically significant pulmonary embolism. Lancet 1992;340:561–4. [4] Konstantinides S, Geibel A, Kasper W, Olschewski M, Blumel L, Just H. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998;97:1946–51. [5] Slebos DJ, Tulleken JE, Ligtenberg JJ, Zijlstra JG, van der Werf TS. A narrow escape: surviving massive pulmonary thromboembolism due to a persistently patent foramen ovale. Intensive Care Med 2000;26:1400. [6] Windecker S, Stortecky S, Meier B. Paradoxical embolism. J Am Coll Cardiol 2014;64: 403–15. [7] Cohnheim I, Thrombose J. und Embolie. Vorlesungen iiber Allgemeine Pathologic, 1. Berlin: Hirschwald; 1877; 134. [8] Brydon C, Fawcett WJ, Treasure T, Clarke JT. Pulmonary embolus and patent foramen ovale: a rare cause of refractory hypoxaemia. Br J Anaesth 1993;71:298–300. [9] Tak T, Soni R, Dave R, Chandraratna PA, Chandrasoma P. Prolonged survival after massive pulmonary embolism in a patient with atrial septal defect and mass in the right ventricle. Can J Cardiol 1997;13:199–202. Please cite this article as: Bagate F, et al, Paradoxical brain embolism shadowing massive pulmonary embolism, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.05.024