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Letter to the Editor
Ischaemic stroke secondary to paradoxical embolism as a consequence of superior vena cava syndrome by a displacement of a ventriculoatrial shunt
Infarto cerebral por embolismo paradójico secundario a síndrome de vena cava superior por malposición de un catéter de derivación ventriculoauricular
J. Molina-Gil
Corresponding author
javimol1993@hotmail.com

Corresponding author.
, S. Calleja-Puerta, M. Rico
Servicio de Neurología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Superior vena cava syndrome &#40;SVCS&#41; is an infrequent condition characterised by a partial or total obstruction of blood flow through the superior vena cava due to extrinsic compression&#44; infiltration&#44; or thrombosis&#46; Progression is variable and sometimes slow&#44; and the condition can even be life-threatening&#59; therefore&#44; it requires a precise diagnosis and early treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of an 82-year-old woman&#44; who was partially dependent and was using a colostomy bag due to perforated diverticulitis&#46; In 2013&#44; she underwent radiosurgery for a petroclival meningioma measuring 4<span class="elsevierStyleHsp" style=""></span>cm&#46; She later developed non-communicating hydrocephalus due to external compression of the meningioma&#46; As ventriculoperitoneal shunt was contraindicated due to the history of colostomy&#44; she underwent ventriculoatrial shunt &#40;VAS&#41; implantation in December 2014 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In May 2019&#44; the patient consulted our department due to global aphasia and right hemiparesis &#40;muscle strength of 2&#47;5&#41;&#44; with onset upon waking&#46; Given suspicion of stroke&#44; we performed a multimodal CT scan&#44; which revealed distal occlusion of the M1 segment of the left middle cerebral artery and favourable mismatch&#46; The patient underwent mechanical thrombectomy&#44; with angiography showing complete reperfusion&#46; Despite this&#44; neurological symptoms improved only slightly&#46; A follow-up CT scan performed 24<span class="elsevierStyleHsp" style=""></span>hours after the procedure revealed an ischaemic lesion involving the left lentiform nucleus and insula&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">During her stay at the stroke unit&#44; the patient presented oedema in the right arm&#44; hindering the insertion of peripheral venous catheters&#46; On the fifth day after admission&#44; we also observed oedema in the face and contralateral arm&#59; examination of the upper limbs yielded normal results&#46; Given the suspicion of SVCS&#44; we performed a Doppler ultrasound of the supra-aortic trunks&#44; which revealed thrombosis of the internal jugular veins&#46; We also requested a non-contrast chest&#44; abdomen&#44; and pelvis CT scan&#44; which initially ruled out extrinsic venous compression or tumour and detected a displacement of the distal end of the VAS in the superior vena cava&#46; A venography of the right arm confirmed thrombosis of the right subclavian vein&#44; the brachiocephalic trunk&#44; and the superior vena cava&#44; with the latter showing contrast passage to the right atrium &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The venous system of the contralateral arm could not be studied due to the inability to insert a peripheral catheter&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">After reassessing the patient&#39;s clinical situation&#44; and having verified the correct functioning of the VAS&#44; we opted for conservative treatment with enoxaparin at a therapeutic dose of 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 12<span class="elsevierStyleHsp" style=""></span>hours&#46; In the following weeks&#44; we observed complete resolution of the facial oedema and partial resolution of the oedema in the arms&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Aetiological study of stroke included a transthoracic echocardiography without echo-enhancing agents&#44; which yielded normal results&#44; and a transcranial Doppler ultrasound right-to-left shunt test&#44; which showed positive results&#44; suggesting a paradoxical embolism from the superior vena cava thrombosis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Global aphasia and right hemiparesis persisted&#46; After clinical stability was achieved&#44; the patient was discharged with prescription of anticoagulation therapy with warfarin at 32<span class="elsevierStyleHsp" style=""></span>mg weekly&#44; for an indefinite period of time&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">SVCS is a complex clinical syndrome whose aetiology has changed over time&#46; The most frequent cause is currently malignant mediastinal neoplasm&#44; especially small-cell lung cancer and non-Hodgkin lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> However&#44; the increasing use of semi-permanent intravascular &#40;venous catheters&#44; haemodialysis&#41; and cardiac devices &#40;pacemakers&#44; defibrillators&#41; has significantly contributed to the appearance of new cases&#44; representing the first non-neoplastic cause of SVCS&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Ventricular shunt is one of the most widely used neurosurgical procedures in the treatment of hydrocephalus&#46; Over the past 20 years&#44; ventriculoperitoneal shunts have preferentially been used due to the technical challenge and the cardiopulmonary and renal complications observed with VAS&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6&#8211;8</span></a> However&#44; no published study has reported cases of SVCS&#44; as observed in our patient&#46; We can only refer to the literature published in the 1960s on children undergoing VAS placement due to hydrocephalus of non-neoplastic origin&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">9&#8211;11</span></a> The postulated mechanism states that atrial contraction during the cardiac cycle favours retrograde transmission of the movement to the rest of the catheter&#44; whereas proximal displacement promotes thrombosis due to reduced mobility of the distal end in the superior vena cava&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Cardioembolic aetiology accounts for 25&#37; of ischaemic strokes&#46; Less frequent cardioembolic causes include patent foramen ovale&#44; which is present in 25&#37; of the general population and is diagnosed in up to 40&#37; of younger patients with otherwise cryptogenic stroke&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">From a therapeutic point of view&#44; endovascular procedures &#40;local fibrinolysis&#44; percutaneous angioplasty&#41; constitute the first line of treatment for SVCS secondary to intravascular devices&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> The functional prognosis of our patient&#44; the risk associated with invasive techniques&#44; and the proper functioning of the VAS led us to opt for conservative treatment&#44; achieving partial symptom resolution&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The interest of this case resides in its unusual form of presentation&#58; ischaemic stroke secondary to paradoxical embolism&#44; which has not previously been reported&#46; In fact&#44; a retrospective series of 70 patients with ischaemic stroke of infrequent aetiology reported no cases of this clinical manifestation&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; considering the possible development of SVCS&#44; it is essential to continuously monitor patients with semi-permanent intravascular devices&#44; as the complications may be catastrophic&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos