Treatment of impending paradoxical embolism with systemic thrombolysis and cerebral embolic protection: a case report

Impending paradoxical embolism is a rare and life-threatening occurrence and evidence guiding its optimal management is lacking.

A 73-year-old man presenting with ST-elevation myocardial infarction was diagnosed with impending paradoxical embolism, as a large thrombus was visualized entrapped in a patent foramen ovale. We performed systemic thrombolysis after deployment of a cerebral protection device, which resulted in complete dissolution of the thrombus without major thromboembolic events. Thrombolysis was complicated by development of intracranial haemorrhage that resolved without major neurological sequelae. The patient was discharged on a direct oral anticoagulant.

Treatment strategies for impending paradoxical embolism include surgical thrombectomy, percutaneous thrombus retrieval, and systemic thrombolysis. We report for the first time the effective use of a cerebral embolic protection device to reduce the risk of ischaemic injury to the brain during systemic thrombolysis.