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Abstract Details

Acute ischemic stroke as a result of paradoxical embolus in a patient with renal cell carcinoma, intravenous tumor thrombus extension, and patent foramen ovale
Cerebrovascular Disease and Interventional Neurology
P11 - Poster Session 11 (8:00 AM-9:00 AM)
4-011
This is the first reported case of intraoperative paradoxical embolism in the setting of renal cell carcinoma with cavoatrial extension and patent foramen ovale.
Patent foramen ovale is a common congenital cardiac abnormality. An association with acute ischemic stroke, secondary to paradoxical embolism of venous blood clots, is well described. Extension of renal cell carcinoma into the adjacent veins is common. Surgical resection is felt to be an effective approach to treatment, even in the setting of extensive venous involvement.
A case report.
A 55-year-old woman with recently diagnosed right renal mass and cavoatrial tumor thrombus was transferred to our facility for surgical resection. She subsequently underwent open radical right nephrectomy, regional lymph node dissection, inferior vena cava and right atrial tumor thrombectomy, and resection of the infrahepatic vena cava. Intraoperative transesophageal echocardiogram confirmed absence of tumor thrombus from the inferior vena cava and right atrium and also identified a patent foramen ovale. Upon weaning sedation, she was noted to be agitated and have left hemiplegia. Her National Institutes of Health Stroke Scale (NIHSS) was 30 and Glasgow Coma Scale (GCS) 6. The CT head revealed extensive hypoattenuation right in the middle and left posterior cerebral artery territories. There was associated cerebral edema and 5mm midline shift. In the setting of devastating neurologic injury, her family elected to transition to comfort care and the patient died on postoperative day 7.

Presence of patent foramen ovale may be a risk factor for severe cerebrovascular complications in the surgical management of renal cell carcinoma with venous involvement. We therefore propose that vigorous screening for PFO be a component of the preoperative workup for RCC with venous involvement. In the event a PFO is discovered pre-operatively, its closure should be contemplated in this population.
Authors/Disclosures
David Gritsch, MD, PhD
PRESENTER 		Dr. Gritsch has nothing to disclose.
Amir A. Mbonde, MD Dr. Mbonde has nothing to disclose.
Abigail M. Taylor, PA (Mayo Clinic Hopsital) Ms. Taylor has nothing to disclose.
No disclosure on file
Bart Demaerschalk, MD, MSc, FRCPC, FÂ鶹´«Ã½Ó³»­ (Mayo Clinic) Dr. Demaerschalk has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Genentech. Dr. Demaerschalk has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Shionogi. Dr. Demaerschalk has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for The Neurologist . The institution of Dr. Demaerschalk has received research support from NICHD.