PARADOXICAL STROKE IN YOUNG MALE WITH SEVERE HYPERCOAGUABLE STATE STATUS POST CAUDA EQUINA SYNDROME

Case Presentation: This is a 37-year-old male presented to ED with bilateral leg numbness and incontinence. An MRI was done that revealed herniation of nucleus pulposus of lumbar intervertebral disc with sciatica and he was taken to the OR for an emergent Full L4 laminectomy, bilateral L4-5 microdiscectomies, bilateral foraminotomies of the S1 nerve roots, bilateral medial facetectomies to correct his cauda equina syndrome. On hospital day 3, he complained of chest pain and had a syncopal event when attempting to ambulate. Rapid response was then called due to severe hypoxia. STAT troponin was drawn and a CTA of the chest was done revealing submissive bilateral pulmonary embolisms. The patient was taken into the IR suite to have an emergent mechanical thrombectomy to remove the bilateral submissive PE’s and R femoropopliteal DVT. The patient was brought to the ICU and heparinized. A neuro exam was done on the patient the following morning that showed substantial change from his baseline and STAT head CT was done. The patient suffered 2 embolic strokes. In addition to that, a large hematoma, ranging from T12-L4 was found at the laminectomy site and required evacuation. heparin stopped as the immediate risk of bleeding outweighed the threat of another VTE and the patient was placed on SCDs. US Doppler revealed another DVT that developed 1 day, SQ heparin was then initiated but despite that, an additional 2 DVTs were found now on the left lower extremity in the posterior tibial and popliteal veins. A TEE with bubble study was done to work up the paradoxical stroke in the setting of TPA and IV Heparin however it initially came back negative. A repeat TEE but this time in the cath lab which finally yielded positive results of a small Patent Foramen Ovale explaining how these paradoxical embolic strokes occurred. However, due to the emergent need for heparinization, we were unable to obtain a proper coagulopathy workup.

Discussion: Patients with a PFO have been reported to have a significantly higher risk of ischemic stroke compared to those without a PFO. Additionally, these patients are more likely to experience large vessel territory strokes. and exhibit greater stroke-related neurological deficits, as measured by the U.S. National Institutes of Health Stroke Scale. A recent meta-analysis encompassing 20.8 million patients evaluated the perioperative stroke risk associated with PFO during noncardiac surgery. The findings revealed a significantly higher incidence of stroke among patients with PFO undergoing orthopedic, general, genitourinary, neurosurgical, and thoracic procedures compared to their non-PFO counterparts.

Conclusions: Increased Stroke Risk in PFO Patients-Patients with a PFO are at significantly higher risk of ischemic stroke compared to those without a PFO, especially during the perioperative period of noncardiac surgeries. This highlights the importance of considering PFO status in preoperative evaluations.Higher Risk in Specific Surgery Types-Certain types of noncardiac surgeries, including orthopedic, general, genitourinary, neurosurgical, and thoracic procedures, are associated with particularly high odds of perioperative stroke in PFO patients. This suggests that these patients may require tailored perioperative management.Severity of Neurological Outcomes-PFO strokes are more likely to involve large vessel territories and result in more severe neurological deficits, as indicated by higher NIHSS scores. This underscores the potential for significant morbidity in this patient population.