SESSION TYPE: Miscellaneous Student/Resident Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Ischemic stroke has a high morbidity and mortality. Cardio-embolic phenomena secondary to congenital anomalies is a common cause of ischemic stroke in the younger population. We present a case of persistent left superior vena cava (PLSVC) leading to stroke.
CASE PRESENTATION: A 54-year-old gentleman with congenital bilateral cleft lip, cleft palate and deafness was transferred to our hospital. Patient was mechanically ventilated, after an elective right hip arthroplasty for respiratory depression from opioids, and reportedly had some involuntary movements. MRI brain revealed subacute right posterior cerebral artery and anterior cerebral artery infarcts. Doppler showed acute deep venous thrombosis (DVT) of left lower extremity. Interestingly, a Chest X-ray done for the confirmation of peripherally inserted central catheter (PICC) placement showed its tip projecting over the left heart border. PLSVC was suspected but arterial catheterization of the PICC could not be excluded, so a blood gas was done which showed oxygen level of 35 mmHg, confirming venous placement. CT angiogram also revealed a PLSVC with a catheter in it along with right upper lobe pulmonary embolism. Trans-esophageal echocardiogram (TEE) with bubble study showed agitated saline injected in the left arm entering the right atrium from the area of the dilated coronary sinus, confirming PLSVC. No left atrial thrombus was seen. The patient was treated with low molecular weight heparin and warfarin and was discharged home on warfarin after extensive physical rehabilitation.
DISCUSSION: PLSVC is the most common anomaly involving central venous return in the thorax with a prevalence of 0.3% in the general population. Approximately 50-70% of these patients are at risk of paradoxical embolism because of accompanying lesions like atrial septal defect, unroofed coronary sinus, or direct communication of the vein to the left atrium. Contrast TEE with left antecubital vein contrast injection is the best diagnostic modality for PLSVC. Our patient is thought to have had a paradoxical embolism reaching the systemic circulation secondary to the PSLVC, causing stroke.
CONCLUSIONS: PLSVC needs to be considered as a cause of stroke in the younger population. Coordination between cardiologist, neurologist and radiologist is the key to diagnosis and management of PLSVC.
1) Hutyra M, Skala T, Sanak D, et al: Persistent left superior vena cava connected through the left upper pulmonary vein to the left atrium: An unusual pathway for paradoxical embolization and a rare cause of recurrent transient ischaemic attack. Eur J Echocardiogr 11:E35, 2010
2) Tak T, Crouch E, Drake GB: Persistent left superior vena cava: Incidence, significance and clinical correlates. Int J Cardiol 82:91-93, 2002
DISCLOSURE: The following authors have nothing to disclose: Akshiv Malhotra, V Subbarao Boppana, Carlos Martinez-Balzano, Anna Orellana
No Product/Research Disclosure InformationSUNY Upstate Medical University, Syracuse, NY