An embolic stroke of undetermined cause that changed to a high‒flow patent foramen ovale after peritoneovenous shunting and was suspected to be due to catheter‒related thrombosis

Abstract

  We report a rare case of catheter‒related thrombosis after a peritoneovenous shunt and embolic stroke of undetermined source (ESUS) with a patent foramen ovale (PFO). A Japanese male in his 70s received a peritoneovenous shunt for intractable ascites due to alcoholic cirrhosis. Since disseminated intravascular coagulation (DIC) often occurs as a postoperative complication, he was treated with a synthetic serine protease inhibitor intra‒ and postoperatively and was discharged from the hospital. On postoperative day 20, he suddenly suffered from left paralysis. He was diagnosed with a right middle cerebral artery cerebral embolism and splenic infarction with hyperthermia and high D‒dimer, but conservative treatment was selected because of his poor general condition. The diagnosis of the stroke type was ESUS. Transthoracic echocardiography confirmed the PFO, but transesophageal echocardiography could not be performed. There was a high possibility of catheter‒related thrombosis as the source of the embolism. We could not identify the causative organism, but the infection resolved after 4 weeks of vancomycin treatment. The diagnosis of paradoxical embolism was not made, as the venous thrombus at the tip of the catheter could not be demonstrated. We hypothesized that the patient originally had a PFO that changed to a high‒risk PFO after peritoneovenous shunting, and that he developed a cerebral infarction due to catheter‒related thrombosis.