Abstract Details

Title Paradoxical Embolism Secondary to Asymptomatic Venous Thoracic Outlet Syndrome

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P8 - Poster Session 8 (8:00 AM-9:00 AM)

Poster/Presentation
Number 13-003

Objective NA

Background Introduction:
Approximately 30-40% of strokes are considered cryptogenic. Identifying etiology is essential to determining appropriate secondary prevention. We describe the case of paradoxical embolic stroke in a young male with PFO, upper extremity deep vein thrombosis (UEDVT), and venous thoracic outlet syndrome (vTOS). vTOS can be asymptomatic and, therefore, missed. Risk factors for vTOS are thought to be a combination of anatomic variants and repeat overhead arm activity, prompting damage to the subclavian vein endothelium.

Design/Methods NA

Results

Presentation:

26-year-old previously healthy male presented after an episode of vision changes and left-sided weakness and was found to have right thalamic acute infarct. Patient had no personal or family history of autoimmune disease, inflammatory disease, thrombophilia, or malignancy. Basic and stroke in young workup was negative, except for a PFO. Bilateral lower extremity (LE) duplex ultrasound was negative. A right UE duplex ultrasound was ordered (after incidental finding of right-sided vTOS on chest imaging), revealing acute DVT in the proximal subclavian vein. As a result, PFO was closed, and the patient was started on anticoagulation.

Conclusions Conclusion:
UEDVTs are considered to have lower risk of embolism compared to LE DVTs. Therefore, we routinely do not screen for UEDVTs unless the patient has risk factors for or symptoms of UEDVT. Our patient did not present with any arm swelling, pain, or cyanosis. In this case, incidental imaging finding of vTOC led to the discovery of a UEDVT as etiology of paradoxical embolic stroke in this patient with a PFO and an otherwise unremarkable workup. On cursory search of PubMed, we found only one other case report of paradoxical stroke with primary etiology of vTOC in contrast to multiple case reports of retrograde propagation of thrombus in the setting of arterial thoracic outlet syndrome highlighting this rare case with a "second hit phenomenon"

Authors/Disclosures
Shumaila Anwer, MD PRESENTER	An immediate family member of Dr. Anwer has received personal compensation for serving as an employee of Southwest Airlines. Dr. Anwer has stock in Boeing.
Alex O'Connor, MD	Alex O'connor has nothing to disclose.
Philip Tatman, MD, PhD	Dr. Tatman has nothing to disclose.
Merry Joseph	Ms. Joseph has nothing to disclose.
Eric Christiansen, MD	Dr. Christiansen has nothing to disclose.
Stephanie Lyden, MD	Dr. Lyden has nothing to disclose.
Vivek Reddy, MD (University of Utah)	Dr. Reddy has nothing to disclose.
Veronica A. Moreno Gomez, MD (Department of Neurology)	Dr. Moreno Gomez has nothing to disclose.

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