Case Reports / Journal of Clinical Neuroscience 22 (2015) 765–767
765
Novel application of pre-operative vertebral body embolization to reduce intraoperative blood loss during a three-column spinal osteotomy for non-oncologic spinal deformity Alexander Tuchman, Vivek A. Mehta, William J. Mack, Frank L. Acosta Jr. ⇑ Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA 90033, USA
a r t i c l e
i n f o
Article history: Received 23 July 2014 Accepted 15 October 2014
Keywords: Estimated blood loss Morbidity Pedicle subtraction osteotomy Spinal deformity Three column osteotomy Vertebral body embolization
a b s t r a c t Three column osteotomies (3CO) of the lumbar spine are powerful corrective procedures used in the treatment of kyphoscoliosis. Their efficacy comes at the cost of high reported complication rates, notably significant estimated blood loss (EBL). Previously reported techniques to reduce EBL have had modest efficacy. Here we describe a potential technique to decrease EBL during pedicle subtraction osteotomy (PSO) of the lumbar spine by means of pre-operative vertebral body embolization – a technique traditionally used to reduce blood loss prior to spinal column tumor resection. We present a 62-year-old man with iatrogenic kyphoscoliosis who underwent staged deformity correction. Stage 1 involved thoracolumbar instrumentation followed by transarterial embolization of the L4 vertebral body through bilateral segmental arteries. A combination of polyvinyl alcohol particles and Gelfoam (Pfizer, New York, NY, USA) were used. Following embolization there was decreased angiographic blood flow to the small vessels of the L4 vertebral body, while the segmental arteries remained patent. Stage 2 consisted of an L4 PSO and fusion. The EBL during the PSO procedure was 1 L, which compared favorably to that during previous PSO at this institution as well as to quantities reported in previous literature. There have been no short term (5 month follow-up) complications attributable to the vertebral body embolization or surgical procedure. Although further investigation into this technique is required to better characterize its safety and efficacy in reducing EBL during 3CO, we believe this patient illustrates the potential utility of preoperative vertebral embolization in the setting of non-oncologic deformity correction surgery. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Three column osteotomies (3CO) of the lumbar spine are powerful corrective procedures for spinal deformity [1]. Their efficacy in the treatment of severe kyphoscoliosis comes at the cost of high reported complication rates ranging between 38–50% [2]. Average estimated blood loss (EBL) among large cohorts of patients receiving 3CO ranges between 1.1–5.8 L [3]. Massive blood loss is an independent risk factor for complications associated with deformity correction surgery [2]. As such, many techniques have been implemented, with varying success, in an attempt to decrease intra-operative blood loss. Previously described methodologies include systemic anti-fibrinolytics, desmopressin acetate, and induced hypotension [3–9]. The use of pre-operative embolization has been well described for reducing EBL during spinal oncology surgery [10]. To our knowledge, however, there are no reports describing the use of pre-operative vertebral embolization for 3CO in patients without spinal tumors. Bone bleeding during a 3CO is usually associated with the most profound blood loss during deformity correction. We aim to describe a technique to decrease EBL during pedicle subtraction osteotomy (PSO) by means of pre-operative vertebral embolization.
(Fig. 1A, B). A staged PSO was planned, as is the standard procedure at our institution. Stage 1 involved thoracolumbar instrumentation followed by transarterial embolization under the same anesthesia. The bilateral L4 lumbar segmental branches were sequentially selected off the aorta with a 5 French Mickelson catheter using standard angiographic techniques. Next, an Echelon 10 microcatheter (ev3 Endovascular, Plymouth, MN, USA) was advanced over a microguidewire into the proximal segmental artery. Next, polyvinyl alcohol 250–500 micron particles were instilled through the microcatheter under subtraction fluoroscopy. Next, small pieces of Gelfoam (Pfizer, New York, NY, USA) were inserted through the Mickelson catheter until sufficiently stagnant opacification was obtained (Fig. 2). On post-operative day 2 the patient returned to the operating room for the planned T2-pelvis posterior spinal fusion and L4 PSO using a combination of 30° templates and osteotomes. The osteotomy was closed with compressive maneuvers followed by rodding and arthrodesis. EBL was 1 L, with approximately 500 cc from the cancellous bone of the L4 vertebral body during the osteotomy. The patient received two units packed red blood cells. He was discharged home on post-operative day 5. He had a significant improvement in his sagittal profile (Fig. 1C, D). At 5 month followup he remains stable with a significantly lower ODI of 30%.
2. Case report A 62-year-old man with a history of several prior lumbar fusions presented with severe back pain from iatrogenic kyphoscoliosis. His Oswestry Disability Index (ODI) was 86%. Standing 36” radiographs revealed his sagittal balance to be +12 cm with a pelvic incidence of 50°, pelvic tilt of 47°, and lumbar lordosis of 20° ⇑ Corresponding author. Tel.: +1 323 226 7421; fax: +1 323 226 7833. E-mail address: [email protected] (F.L. Acosta Jr.).
3. Discussion Massive blood loss is a significant risk during spinal deformity surgery. Previously described techniques, while showing some promise, have not fully resolved this issue. Intra-operative anti-fibrinolytics such as aprotinin have been found to be effective in reducing blood loss associated with complex spinal deformity procedures [3,9]; however, its use has recently become more contro-
766
Case Reports / Journal of Clinical Neuroscience 22 (2015) 765–767
Fig. 1. Pre-operative anteroposterior (A) and lateral (B) standing scoliosis radiographs. Post-operative anteroposterior (C) and lateral (D) standing scoliosis radiographs.
versial due to reported associations with post-operative renal failure, myocardial infarction, stroke, and death [7]. Tranexamic acid has been used in its place with promising results for reducing blood loss in spine patients in general, but mixed results in the adult deformity population [3,6]. Multiple investigations into desmopressin acetate have shown it to be useful only in patients with documented coagulopathy [8]. Induced hypotension has also been described but can be associated with myocardial ischemia and vision loss [4,5]. Spinal embolization has proven to be safe and efficacious in the setting of spinal column tumor resection [10]. To our knowledge it has not been described for decreasing blood flow to a ‘‘normal” vertebral body, but the surgical principles should be similar. In our patient there were no short-term complications related to the embolization. Intra-operatively we noted decreased bleeding from the L4 body and total EBL was 1.0 L. This compares favorably to EBL during our previous 10 3CO without embolization, which averaged 2.7 L (range 1.9–3.9 L). Our embolization was deliberately conservative with the angiographic goal to maintain flow through the segmental arteries while obliterating the vertebral blush. Our concern was that overzealous embolization could lead to difficulties with osteotomy fusion. Although this account carries with it the significant limitations of any isolated case report, we believe it illustrates the concept that vertebral body embolization can be safely performed without any short-term complications and may reduce EBL during 3CO for patients with non-neoplastic spinal deformity. Further investigation into this technique is needed and the benefits of reducing EBL must certainly be balanced against the risks and costs of the embolization procedure.
Conflicts of Interest The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. Fig. 2. (A) Pre-embolization anteroposterior angiogram via microcatheter injection through the right L4 segmental artery showing normal hemivertebral blush (arrow). (B) After polyvinyl alcohol-Gelfoam (Pfizer, New York, NY, USA) embolization anteroposterior angiogram via microcatheter injection through the right L4 segmental artery showing obliteration of hemivertebral blush (arrow).
References [1] Gill JB, Levin A, Burd T, et al. Corrective osteotomies in spine surgery. J Bone Joint Surg Am 2008;90:2509–20.
Case Reports / Journal of Clinical Neuroscience 22 (2015) 767–768 [2] Kim SS, Cho BC, Kim JH, et al. Complications of posterior vertebral resection for spinal deformity. Asian Spine J 2012;6:257–65. [3] Dorward IG, Lenke LG. Osteotomies in the posterior-only treatment of complex adult spinal deformity: a comparative review. Neurosurg Focus 2010;28:E4. [4] Grundy BL, Nash Jr CL, Brown RH. Arterial pressure manipulation alters spinal cord function during correction of scoliosis. Anesthesiology 1981;54:249–53. [5] Hwang W, Kim E. The effect of milrinone on induced hypotension in elderly patients during spinal surgery: a randomized controlled trial. Spine J 2014;14:1532–7. [6] Li ZJ, Fu X, Xing D, et al. Is tranexamic acid effective and safe in spinal surgery? A meta-analysis of randomized controlled trials. Eur Spine J 2013;22:1950–7.
767
[7] Mangano DT, Miao Y, Vuylsteke A, et al. Mortality associated with aprotinin during 5 years following coronary artery bypass graft surgery. JAMA 2007;297:471–9. [8] Szpalski M, Gunzburg R, Sztern B. An overview of blood-sparing techniques used in spine surgery during the perioperative period. Eur Spine J 2004;13: S18–27. [9] Tayyab NA, Mariller MM, Rivlin M, et al. Efficacy of aprotinin as a blood conservation technique for adult deformity spinal surgery: a retrospective study. Spine (Phila Pa 1976) 2008;33:1775–81. [10] Kato S, Murakami H, Minami T, et al. Preoperative embolization significantly decreases intraoperative blood loss during palliative surgery for spinal metastasis. Orthopedics 2012;35:1389–95.
http://dx.doi.org/10.1016/j.jocn.2014.10.015
Ischemic stroke related to an amniotic fluid embolism during labor Yeon-Sun Woo a, Soon-Cheol Hong b, Seong-Mi Park c, Kyung-Hee Cho a,⇑ a
Department of Neurology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul 136-705, Republic of Korea Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea c Department of Cardiology, Korea University College of Medicine, Seoul, Republic of Korea b
a r t i c l e
i n f o
Article history: Received 22 August 2014 Accepted 25 October 2014
Keywords: Amniotic fluid embolism Patent foramen ovale Pregnant women Stroke
a b s t r a c t We report a young woman who survived multiple cerebral infarctions related to an amniotic fluid embolism (AFE) during labor. To our knowledge, an embolic stroke due to the coexistence of an AFE and patent foramen ovale (PFO) has not been reported. We describe the patient’s clinical and radiological features and discuss the stroke mechanism in relation to our AFE hypothesis. A 32-year-old woman presented to the emergency room after experiencing convulsions during labor (blood pressure, 64/28 mmHg; oxygen saturation, 67%). She was in a stupor, and her response to painful stimuli on the right side was weaker than on the left side. Acute stroke was considered as a possible cause. Additionally, an AFE was suspected due to cardiopulmonary arrest during labor. Brain MRI revealed multiple territory embolic infarctions. The transcranial Doppler with bubble study demonstrated a right-to-left shunt during the Valsalva maneuver. A transesophageal echocardiogram revealed a PFO with a right-to-left shunt. The elevated intrathoracic pressure during labor may have caused blood to flow backward through the heart, shunting blood from the right side to the left through the PFO. In cases such as this, an amniotic fluid embolus may travel directly from the venous to the arterial circulation via the PFO, leading to multiple cerebral infarctions. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Amniotic fluid embolism (AFE) is rare and can only be diagnosed after exclusion of all other potential causes [1]. In patients with an AFE, the focal neurologic deficits that suggest acute stroke may not be present [2]. In addition, the coexistence of an AFE and patent foramen ovale (PFO) is extremely rare. We report a woman who survived an acute ischemic stroke related to an AFE. 2. Case report A 32-year-old woman presented to the emergency room after experiencing convulsions during labor. It was her first normal pregnancy with a full-term delivery at 38 weeks of gestation. There was no relevant medical history of epilepsy or stroke. Her initial vital signs were unstable (blood pressure 64/28 mmHg). She was in a stupor, and her response to painful stimuli on the right side was obviously weaker than on the left side. Acute stroke or status epilepticus were considered as possible causes, and AFE was also considered due to cardiopulmonary arrest during labor. Her hemoglobin level was 7.6 g/dL (normal range: 11.7–15.5 g/dL), hemato⇑ Corresponding author. Tel.: +82 2 920 6838; fax: +82 2 926 5347. E-mail address: [email protected] (K.-H. Cho).
crit was 23.3% (normal range: 35–45%), platelet count was 122,000/lL (normal range: 150,000–450,000/lL), prothrombin time was >120 s (normal range: 12.0–14.3 s), and activated partial thromboplastin time was >180 s (normal range: 30.7–43.0 s). Other blood coagulation tests showed a decreased fibrinogen (20 ug/dL, normal range: 0–5 ug/dL), and an increased D-dimer (>20 ug/mL, normal range: 0–0.5 ug/mL). These abnormal laboratory findings suggested disseminated intravascular coagulation (DIC), which likely developed secondary to the AFE. Vaginal bleeding continued, suggesting that it may be due to coagulopathy. Uterine arteriography and embolization were performed. Status epilepticus was excluded after performing an electroencephalogram. Five days post-admission, the patient’s vital signs stabilized, and diffusion-weighted imaging of the brain showed multiple embolic infarctions in the frontoparietal cortices, corona radiata, and right cerebellum (Fig. 1A–D). Brain magnetic resonance angiography was normal. The transcranial Doppler with bubble study demonstrated a right-to-left shunt during the Valsalva maneuver (Fig. 1E), and the transesophageal echocardiogram (ECG) showed a PFO with a right-to-left shunt (Fig. 1F). She was treated with anticoagulation for the secondary prevention of ischemic stroke.
765
Novel application of pre-operative vertebral body embolization to reduce intraoperative blood loss during a three-column spinal osteotomy for non-oncologic spinal deformity Alexander Tuchman, Vivek A. Mehta, William J. Mack, Frank L. Acosta Jr. ⇑ Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA 90033, USA
a r t i c l e
i n f o
Article history: Received 23 July 2014 Accepted 15 October 2014
Keywords: Estimated blood loss Morbidity Pedicle subtraction osteotomy Spinal deformity Three column osteotomy Vertebral body embolization
a b s t r a c t Three column osteotomies (3CO) of the lumbar spine are powerful corrective procedures used in the treatment of kyphoscoliosis. Their efficacy comes at the cost of high reported complication rates, notably significant estimated blood loss (EBL). Previously reported techniques to reduce EBL have had modest efficacy. Here we describe a potential technique to decrease EBL during pedicle subtraction osteotomy (PSO) of the lumbar spine by means of pre-operative vertebral body embolization – a technique traditionally used to reduce blood loss prior to spinal column tumor resection. We present a 62-year-old man with iatrogenic kyphoscoliosis who underwent staged deformity correction. Stage 1 involved thoracolumbar instrumentation followed by transarterial embolization of the L4 vertebral body through bilateral segmental arteries. A combination of polyvinyl alcohol particles and Gelfoam (Pfizer, New York, NY, USA) were used. Following embolization there was decreased angiographic blood flow to the small vessels of the L4 vertebral body, while the segmental arteries remained patent. Stage 2 consisted of an L4 PSO and fusion. The EBL during the PSO procedure was 1 L, which compared favorably to that during previous PSO at this institution as well as to quantities reported in previous literature. There have been no short term (5 month follow-up) complications attributable to the vertebral body embolization or surgical procedure. Although further investigation into this technique is required to better characterize its safety and efficacy in reducing EBL during 3CO, we believe this patient illustrates the potential utility of preoperative vertebral embolization in the setting of non-oncologic deformity correction surgery. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Three column osteotomies (3CO) of the lumbar spine are powerful corrective procedures for spinal deformity [1]. Their efficacy in the treatment of severe kyphoscoliosis comes at the cost of high reported complication rates ranging between 38–50% [2]. Average estimated blood loss (EBL) among large cohorts of patients receiving 3CO ranges between 1.1–5.8 L [3]. Massive blood loss is an independent risk factor for complications associated with deformity correction surgery [2]. As such, many techniques have been implemented, with varying success, in an attempt to decrease intra-operative blood loss. Previously described methodologies include systemic anti-fibrinolytics, desmopressin acetate, and induced hypotension [3–9]. The use of pre-operative embolization has been well described for reducing EBL during spinal oncology surgery [10]. To our knowledge, however, there are no reports describing the use of pre-operative vertebral embolization for 3CO in patients without spinal tumors. Bone bleeding during a 3CO is usually associated with the most profound blood loss during deformity correction. We aim to describe a technique to decrease EBL during pedicle subtraction osteotomy (PSO) by means of pre-operative vertebral embolization.
(Fig. 1A, B). A staged PSO was planned, as is the standard procedure at our institution. Stage 1 involved thoracolumbar instrumentation followed by transarterial embolization under the same anesthesia. The bilateral L4 lumbar segmental branches were sequentially selected off the aorta with a 5 French Mickelson catheter using standard angiographic techniques. Next, an Echelon 10 microcatheter (ev3 Endovascular, Plymouth, MN, USA) was advanced over a microguidewire into the proximal segmental artery. Next, polyvinyl alcohol 250–500 micron particles were instilled through the microcatheter under subtraction fluoroscopy. Next, small pieces of Gelfoam (Pfizer, New York, NY, USA) were inserted through the Mickelson catheter until sufficiently stagnant opacification was obtained (Fig. 2). On post-operative day 2 the patient returned to the operating room for the planned T2-pelvis posterior spinal fusion and L4 PSO using a combination of 30° templates and osteotomes. The osteotomy was closed with compressive maneuvers followed by rodding and arthrodesis. EBL was 1 L, with approximately 500 cc from the cancellous bone of the L4 vertebral body during the osteotomy. The patient received two units packed red blood cells. He was discharged home on post-operative day 5. He had a significant improvement in his sagittal profile (Fig. 1C, D). At 5 month followup he remains stable with a significantly lower ODI of 30%.
2. Case report A 62-year-old man with a history of several prior lumbar fusions presented with severe back pain from iatrogenic kyphoscoliosis. His Oswestry Disability Index (ODI) was 86%. Standing 36” radiographs revealed his sagittal balance to be +12 cm with a pelvic incidence of 50°, pelvic tilt of 47°, and lumbar lordosis of 20° ⇑ Corresponding author. Tel.: +1 323 226 7421; fax: +1 323 226 7833. E-mail address: [email protected] (F.L. Acosta Jr.).
3. Discussion Massive blood loss is a significant risk during spinal deformity surgery. Previously described techniques, while showing some promise, have not fully resolved this issue. Intra-operative anti-fibrinolytics such as aprotinin have been found to be effective in reducing blood loss associated with complex spinal deformity procedures [3,9]; however, its use has recently become more contro-
766
Case Reports / Journal of Clinical Neuroscience 22 (2015) 765–767
Fig. 1. Pre-operative anteroposterior (A) and lateral (B) standing scoliosis radiographs. Post-operative anteroposterior (C) and lateral (D) standing scoliosis radiographs.
versial due to reported associations with post-operative renal failure, myocardial infarction, stroke, and death [7]. Tranexamic acid has been used in its place with promising results for reducing blood loss in spine patients in general, but mixed results in the adult deformity population [3,6]. Multiple investigations into desmopressin acetate have shown it to be useful only in patients with documented coagulopathy [8]. Induced hypotension has also been described but can be associated with myocardial ischemia and vision loss [4,5]. Spinal embolization has proven to be safe and efficacious in the setting of spinal column tumor resection [10]. To our knowledge it has not been described for decreasing blood flow to a ‘‘normal” vertebral body, but the surgical principles should be similar. In our patient there were no short-term complications related to the embolization. Intra-operatively we noted decreased bleeding from the L4 body and total EBL was 1.0 L. This compares favorably to EBL during our previous 10 3CO without embolization, which averaged 2.7 L (range 1.9–3.9 L). Our embolization was deliberately conservative with the angiographic goal to maintain flow through the segmental arteries while obliterating the vertebral blush. Our concern was that overzealous embolization could lead to difficulties with osteotomy fusion. Although this account carries with it the significant limitations of any isolated case report, we believe it illustrates the concept that vertebral body embolization can be safely performed without any short-term complications and may reduce EBL during 3CO for patients with non-neoplastic spinal deformity. Further investigation into this technique is needed and the benefits of reducing EBL must certainly be balanced against the risks and costs of the embolization procedure.
Conflicts of Interest The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication. Fig. 2. (A) Pre-embolization anteroposterior angiogram via microcatheter injection through the right L4 segmental artery showing normal hemivertebral blush (arrow). (B) After polyvinyl alcohol-Gelfoam (Pfizer, New York, NY, USA) embolization anteroposterior angiogram via microcatheter injection through the right L4 segmental artery showing obliteration of hemivertebral blush (arrow).
References [1] Gill JB, Levin A, Burd T, et al. Corrective osteotomies in spine surgery. J Bone Joint Surg Am 2008;90:2509–20.
Case Reports / Journal of Clinical Neuroscience 22 (2015) 767–768 [2] Kim SS, Cho BC, Kim JH, et al. Complications of posterior vertebral resection for spinal deformity. Asian Spine J 2012;6:257–65. [3] Dorward IG, Lenke LG. Osteotomies in the posterior-only treatment of complex adult spinal deformity: a comparative review. Neurosurg Focus 2010;28:E4. [4] Grundy BL, Nash Jr CL, Brown RH. Arterial pressure manipulation alters spinal cord function during correction of scoliosis. Anesthesiology 1981;54:249–53. [5] Hwang W, Kim E. The effect of milrinone on induced hypotension in elderly patients during spinal surgery: a randomized controlled trial. Spine J 2014;14:1532–7. [6] Li ZJ, Fu X, Xing D, et al. Is tranexamic acid effective and safe in spinal surgery? A meta-analysis of randomized controlled trials. Eur Spine J 2013;22:1950–7.
767
[7] Mangano DT, Miao Y, Vuylsteke A, et al. Mortality associated with aprotinin during 5 years following coronary artery bypass graft surgery. JAMA 2007;297:471–9. [8] Szpalski M, Gunzburg R, Sztern B. An overview of blood-sparing techniques used in spine surgery during the perioperative period. Eur Spine J 2004;13: S18–27. [9] Tayyab NA, Mariller MM, Rivlin M, et al. Efficacy of aprotinin as a blood conservation technique for adult deformity spinal surgery: a retrospective study. Spine (Phila Pa 1976) 2008;33:1775–81. [10] Kato S, Murakami H, Minami T, et al. Preoperative embolization significantly decreases intraoperative blood loss during palliative surgery for spinal metastasis. Orthopedics 2012;35:1389–95.
http://dx.doi.org/10.1016/j.jocn.2014.10.015
Ischemic stroke related to an amniotic fluid embolism during labor Yeon-Sun Woo a, Soon-Cheol Hong b, Seong-Mi Park c, Kyung-Hee Cho a,⇑ a
Department of Neurology, Korea University College of Medicine, 73 Inchon-ro, Seongbuk-gu, Seoul 136-705, Republic of Korea Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea c Department of Cardiology, Korea University College of Medicine, Seoul, Republic of Korea b
a r t i c l e
i n f o
Article history: Received 22 August 2014 Accepted 25 October 2014
Keywords: Amniotic fluid embolism Patent foramen ovale Pregnant women Stroke
a b s t r a c t We report a young woman who survived multiple cerebral infarctions related to an amniotic fluid embolism (AFE) during labor. To our knowledge, an embolic stroke due to the coexistence of an AFE and patent foramen ovale (PFO) has not been reported. We describe the patient’s clinical and radiological features and discuss the stroke mechanism in relation to our AFE hypothesis. A 32-year-old woman presented to the emergency room after experiencing convulsions during labor (blood pressure, 64/28 mmHg; oxygen saturation, 67%). She was in a stupor, and her response to painful stimuli on the right side was weaker than on the left side. Acute stroke was considered as a possible cause. Additionally, an AFE was suspected due to cardiopulmonary arrest during labor. Brain MRI revealed multiple territory embolic infarctions. The transcranial Doppler with bubble study demonstrated a right-to-left shunt during the Valsalva maneuver. A transesophageal echocardiogram revealed a PFO with a right-to-left shunt. The elevated intrathoracic pressure during labor may have caused blood to flow backward through the heart, shunting blood from the right side to the left through the PFO. In cases such as this, an amniotic fluid embolus may travel directly from the venous to the arterial circulation via the PFO, leading to multiple cerebral infarctions. Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction Amniotic fluid embolism (AFE) is rare and can only be diagnosed after exclusion of all other potential causes [1]. In patients with an AFE, the focal neurologic deficits that suggest acute stroke may not be present [2]. In addition, the coexistence of an AFE and patent foramen ovale (PFO) is extremely rare. We report a woman who survived an acute ischemic stroke related to an AFE. 2. Case report A 32-year-old woman presented to the emergency room after experiencing convulsions during labor. It was her first normal pregnancy with a full-term delivery at 38 weeks of gestation. There was no relevant medical history of epilepsy or stroke. Her initial vital signs were unstable (blood pressure 64/28 mmHg). She was in a stupor, and her response to painful stimuli on the right side was obviously weaker than on the left side. Acute stroke or status epilepticus were considered as possible causes, and AFE was also considered due to cardiopulmonary arrest during labor. Her hemoglobin level was 7.6 g/dL (normal range: 11.7–15.5 g/dL), hemato⇑ Corresponding author. Tel.: +82 2 920 6838; fax: +82 2 926 5347. E-mail address: [email protected] (K.-H. Cho).
crit was 23.3% (normal range: 35–45%), platelet count was 122,000/lL (normal range: 150,000–450,000/lL), prothrombin time was >120 s (normal range: 12.0–14.3 s), and activated partial thromboplastin time was >180 s (normal range: 30.7–43.0 s). Other blood coagulation tests showed a decreased fibrinogen (20 ug/dL, normal range: 0–5 ug/dL), and an increased D-dimer (>20 ug/mL, normal range: 0–0.5 ug/mL). These abnormal laboratory findings suggested disseminated intravascular coagulation (DIC), which likely developed secondary to the AFE. Vaginal bleeding continued, suggesting that it may be due to coagulopathy. Uterine arteriography and embolization were performed. Status epilepticus was excluded after performing an electroencephalogram. Five days post-admission, the patient’s vital signs stabilized, and diffusion-weighted imaging of the brain showed multiple embolic infarctions in the frontoparietal cortices, corona radiata, and right cerebellum (Fig. 1A–D). Brain magnetic resonance angiography was normal. The transcranial Doppler with bubble study demonstrated a right-to-left shunt during the Valsalva maneuver (Fig. 1E), and the transesophageal echocardiogram (ECG) showed a PFO with a right-to-left shunt (Fig. 1F). She was treated with anticoagulation for the secondary prevention of ischemic stroke.
