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Paradoxical embolism

2020-06-12T06:08:56Z

Muhammad Haisum Maqsood: /* Overview */

{{SI}}

{{CMG}} {{Hira Rehman}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation . If dislodged into brain, it could cause end-organ ischemia depending on site of blockade e.g brain, kidney, gut, limb and/or heart etc.

== Etiology ==
It can occur from any condition with any condition with breach in a barrier between right and left sided circulation of heart. <ref name=":0" />The most common pre-existing conditions that results in mixing of arterial and venous blood and eventually lead to paradoxical embolism include:

# Patent Foramen Ovale
# Atrial Septal Defect
# Arteriovenous Shunts
# Ventricular Septal Defects

Factors that enhance clotting mechanism beyond physiological requirements elevate the risks of incidence of paradoxical embolism e.g. genetic disorders of hypercoagulation (factor V Leiden deficiency, anti-thrombin III deficiency, protein C and S deficiency), increased estrogen levels (pregnancies and use of oral contraceptive pills), immobilization (related to surgery or disability) and malignancies .
==Pathophysiology and Presentation==
The prerequisites for paradoxical embolism include presence of blood clot on the veins and their eventual bypass passage from venous to arterial blood systems through a breach in integrity of separating right and left sides of heart . When already present clot in form of deep vein thrombosis which is mostly in veins of lower extremities dislodges, it traverses through the right side to the left side of heart and eventually through systemic circulation lodges in end-artery. The manifestation of symptoms depend on size of clot and vessels blocked. The most commonly blocked vessels include:

#Cerebral Arteries (leading to stroke)
#Mesenteric Arteries (leading to acute or chronic mesenteric ischemia)
#Femoral Artery (limb ischemic)
#Renal Artery (renal infarction)
#Coronary Artery (acute myocardial infarction)

==Differential Diagnoses==

# Deep vein thrombosis
# Endocarditis
# Atrial fibrillation leading to clot formation

==Work Up==
Paradoxical embolism is a diagnosis of exclusion which needs extensive laboratory work up to exclude other causes of possible symptoms manifestation. However, three conditions are required to meet clinical diagnosis <ref name=":1" />:

# Venous source of embolism
# Presence of intracardiac shunt or pulmonary fistula
# Arterial blockage

For detection of hypercoagulability, factor V Leiden assays and levels of anti-thrombin III, protein C and S are required.

Specialized studies for detection of intra-cardiac shunts include:

'''''Echocardiography'''''

Transthoracic and tranesophageal echocardiographies could be used for detection of intra-cardiac shunt anomalies. Due to non-invasive nature of transthoracic echocardiography, it is mostly used. This method is mostly used for detection of site and size of intra-cardiac defect .

Bubble study using echocardiography could be used for detection of small intra-cardiac defects. Saline with bubbles is injected through peripheral veins and the detection of bubbles on left side of heart through echocardiogram confirms the presence of intra-cardiac defect .

'''''Transcranial Doppler Sonography'''''

This method is traditionally used for detection of right-to-left cardiac shunts in conjunction with transesophageal echocardiography. Contrast saline with bubbles is injected in venous blood and patient is also to do Valsalva maneuver . Detection of microemboli in middle cerebral vessel through transcranial doppler sonography in conjunction with evidence of intra-cardiac defect via transesophageal echocardiography confirms the presence of defect <ref name=":2" />.

'''''Computed Tomography Resonance'''''

It produced a high resolution imaging of cardiac structure and its vasculature with high sensitivity and specificity . However, it's not commonly used as it could potentially damage heart with exposure to ionizing radiations<ref name=":3" />. Further, it could not evaluate functional aspects.
==Management==
'''Acute management''' of paradoxical embolism is dependent on specific organ involvement. Generally, the aim is to remove clot to avoid irreversible damage to organs. If cranial and coronary vasculature are involved, patients are treated on basis of stroke and acute myocardial infarction management guidelines, respectively.

'''Secondary Prevention''' aims at risk factors that lead to formation of clots and their passage through intra-cardiac shunts.

* Aspirin, an oral anticoagulant, is used to prevent formation of clots .
* Percutaneous closure of intracardiac shunt (closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]) is an outpatient procedure with minimal complications . Surgical Closure of intracardiac shunts is associated with operation related complications.
* Placement of a [[inferior vena cava]] ([[IVC]]) filter in patients with recurrent lower extremity deep vein thrombosis and contraindicated to anti-coagulants.
* Discontinuation of [[birth control pill]]s if patient is taking prior to the embolism.
* Smoking cessation for smokers.

== References ==
[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
<references group="Windecker S, Stortecky S, Meier B. Paradoxical embolism. Journal of the American College of Cardiology. 2014 Jul 29;64(4):403-15." /> 
<references />

Paradoxical embolism

2020-06-12T06:07:47Z

Muhammad Haisum Maqsood: /* Management */

{{SI}}

{{CMG}} {{Hira Rehman}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, cryptogenic stroke, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation . If dislodged into brain, it could cause end-organ ischemia depending on site of blockade e.g brain, kidney, gut, limb and/or heart etc.

== Etiology ==
It can occur from any condition with any condition with breach in a barrier between right and left sided circulation of heart. <ref name=":0" />The most common pre-existing conditions that results in mixing of arterial and venous blood and eventually lead to paradoxical embolism include:

# Patent Foramen Ovale
# Atrial Septal Defect
# Arteriovenous Shunts
# Ventricular Septal Defects

Factors that enhance clotting mechanism beyond physiological requirements elevate the risks of incidence of paradoxical embolism e.g. genetic disorders of hypercoagulation (factor V Leiden deficiency, anti-thrombin III deficiency, protein C and S deficiency), increased estrogen levels (pregnancies and use of oral contraceptive pills), immobilization (related to surgery or disability) and malignancies .
==Pathophysiology and Presentation==
The prerequisites for paradoxical embolism include presence of blood clot on the veins and their eventual bypass passage from venous to arterial blood systems through a breach in integrity of separating right and left sides of heart . When already present clot in form of deep vein thrombosis which is mostly in veins of lower extremities dislodges, it traverses through the right side to the left side of heart and eventually through systemic circulation lodges in end-artery. The manifestation of symptoms depend on size of clot and vessels blocked. The most commonly blocked vessels include:

#Cerebral Arteries (leading to stroke)
#Mesenteric Arteries (leading to acute or chronic mesenteric ischemia)
#Femoral Artery (limb ischemic)
#Renal Artery (renal infarction)
#Coronary Artery (acute myocardial infarction)

==Differential Diagnoses==

# Deep vein thrombosis
# Endocarditis
# Atrial fibrillation leading to clot formation

==Work Up==
Paradoxical embolism is a diagnosis of exclusion which needs extensive laboratory work up to exclude other causes of possible symptoms manifestation. However, three conditions are required to meet clinical diagnosis <ref name=":1" />:

# Venous source of embolism
# Presence of intracardiac shunt or pulmonary fistula
# Arterial blockage

For detection of hypercoagulability, factor V Leiden assays and levels of anti-thrombin III, protein C and S are required.

Specialized studies for detection of intra-cardiac shunts include:

'''''Echocardiography'''''

Transthoracic and tranesophageal echocardiographies could be used for detection of intra-cardiac shunt anomalies. Due to non-invasive nature of transthoracic echocardiography, it is mostly used. This method is mostly used for detection of site and size of intra-cardiac defect .

Bubble study using echocardiography could be used for detection of small intra-cardiac defects. Saline with bubbles is injected through peripheral veins and the detection of bubbles on left side of heart through echocardiogram confirms the presence of intra-cardiac defect .

'''''Transcranial Doppler Sonography'''''

This method is traditionally used for detection of right-to-left cardiac shunts in conjunction with transesophageal echocardiography. Contrast saline with bubbles is injected in venous blood and patient is also to do Valsalva maneuver . Detection of microemboli in middle cerebral vessel through transcranial doppler sonography in conjunction with evidence of intra-cardiac defect via transesophageal echocardiography confirms the presence of defect <ref name=":2" />.

'''''Computed Tomography Resonance'''''

It produced a high resolution imaging of cardiac structure and its vasculature with high sensitivity and specificity . However, it's not commonly used as it could potentially damage heart with exposure to ionizing radiations<ref name=":3" />. Further, it could not evaluate functional aspects.
==Management==
'''Acute management''' of paradoxical embolism is dependent on specific organ involvement. Generally, the aim is to remove clot to avoid irreversible damage to organs. If cranial and coronary vasculature are involved, patients are treated on basis of stroke and acute myocardial infarction management guidelines, respectively.

'''Secondary Prevention''' aims at risk factors that lead to formation of clots and their passage through intra-cardiac shunts.

* Aspirin, an oral anticoagulant, is used to prevent formation of clots <ref>{{Cite journal|last=et al|first=J P Mohr, J L Thompson, R M Lazar|date=2001|title=A Comparison of Warfarin and Aspirin for the Prevention of Recurrent Ischemic Stroke|url=https://pubmed.ncbi.nlm.nih.gov/11794192/?dopt=Abstract|journal=N Engl J Med|volume=345|pages=1444-51|via=}}</ref>.
* Percutaneous closure of intracardiac shunt (closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]) is an outpatient procedure with minimal complications <ref>{{Cite journal|last=|first=Wöhrle J|date=2006|title=Closure of patent foramen ovale after cryptogenic stroke|url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69087-9/fulltext|journal=The Lancet|volume=|pages=|via=}}</ref>. Surgical Closure of intracardiac shunts is associated with operation related complications.
* Placement of a [[inferior vena cava]] ([[IVC]]) filter in patients with recurrent lower extremity deep vein thrombosis and contraindicated to anti-coagulants.
* Discontinuation of [[birth control pill]]s if patient is taking prior to the embolism.
* Smoking cessation for smokers.

== References ==
[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
<references group="Windecker S, Stortecky S, Meier B. Paradoxical embolism. Journal of the American College of Cardiology. 2014 Jul 29;64(4):403-15." /> 
<references />

Paradoxical embolism

2020-06-12T06:02:05Z

Muhammad Haisum Maqsood: /* Overview */

{{SI}}

{{CMG}} {{Hira Rehman}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, cryptogenic stroke, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation . If dislodged into brain, it could cause end-organ ischemia depending on site of blockade e.g brain, kidney, gut, limb and/or heart etc.

== Etiology ==
It can occur from any condition with any condition with breach in a barrier between right and left sided circulation of heart. <ref name=":0" />The most common pre-existing conditions that results in mixing of arterial and venous blood and eventually lead to paradoxical embolism include:

# Patent Foramen Ovale
# Atrial Septal Defect
# Arteriovenous Shunts
# Ventricular Septal Defects

Factors that enhance clotting mechanism beyond physiological requirements elevate the risks of incidence of paradoxical embolism e.g. genetic disorders of hypercoagulation (factor V Leiden deficiency, anti-thrombin III deficiency, protein C and S deficiency), increased estrogen levels (pregnancies and use of oral contraceptive pills), immobilization (related to surgery or disability) and malignancies .
==Pathophysiology and Presentation==
The prerequisites for paradoxical embolism include presence of blood clot on the veins and their eventual bypass passage from venous to arterial blood systems through a breach in integrity of separating right and left sides of heart . When already present clot in form of deep vein thrombosis which is mostly in veins of lower extremities dislodges, it traverses through the right side to the left side of heart and eventually through systemic circulation lodges in end-artery. The manifestation of symptoms depend on size of clot and vessels blocked. The most commonly blocked vessels include:

#Cerebral Arteries (leading to stroke)
#Mesenteric Arteries (leading to acute or chronic mesenteric ischemia)
#Femoral Artery (limb ischemic)
#Renal Artery (renal infarction)
#Coronary Artery (acute myocardial infarction)

==Differential Diagnoses==

# Deep vein thrombosis
# Endocarditis
# Atrial fibrillation leading to clot formation

==Work Up==
Paradoxical embolism is a diagnosis of exclusion which needs extensive laboratory work up to exclude other causes of possible symptoms manifestation. However, three conditions are required to meet clinical diagnosis <ref name=":1" />:

# Venous source of embolism
# Presence of intracardiac shunt or pulmonary fistula
# Arterial blockage

For detection of hypercoagulability, factor V Leiden assays and levels of anti-thrombin III, protein C and S are required.

Specialized studies for detection of intra-cardiac shunts include:

'''''Echocardiography'''''

Transthoracic and tranesophageal echocardiographies could be used for detection of intra-cardiac shunt anomalies. Due to non-invasive nature of transthoracic echocardiography, it is mostly used. This method is mostly used for detection of site and size of intra-cardiac defect .

Bubble study using echocardiography could be used for detection of small intra-cardiac defects. Saline with bubbles is injected through peripheral veins and the detection of bubbles on left side of heart through echocardiogram confirms the presence of intra-cardiac defect .

'''''Transcranial Doppler Sonography'''''

This method is traditionally used for detection of right-to-left cardiac shunts in conjunction with transesophageal echocardiography. Contrast saline with bubbles is injected in venous blood and patient is also to do Valsalva maneuver . Detection of microemboli in middle cerebral vessel through transcranial doppler sonography in conjunction with evidence of intra-cardiac defect via transesophageal echocardiography confirms the presence of defect <ref name=":2" />.

'''''Computed Tomography Resonance'''''

It produced a high resolution imaging of cardiac structure and its vasculature with high sensitivity and specificity . However, it's not commonly used as it could potentially damage heart with exposure to ionizing radiations<ref name=":3" />. Further, it could not evaluate functional aspects.
==Management==
'''Acute management''' of paradoxical embolism is dependent on specific organ involvement. Generally, the aim is to remove clot to avoid irreversible damage to organs. If cranial and coronary vasculature are involved, patients are treated on basis of stroke and acute myocardial infarction management guidelines, respectively.

'''Secondary Prevention''' aims at risk factors that lead to formation of clots and their passage through intra-cardiac shunts.

* Aspirin, an oral anticoagulant, is used to prevent formation of clots.
* Percutaneous closure of intracardiac shunt (closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]) is an outpatient procedure with minimal complications. Surgical Closure of intracardiac shunts is associated with operation related complications.
* Placement of a [[inferior vena cava]] ([[IVC]]) filter in patients with recurrent lower extremity deep vein thrombosis and contraindicated to anti-coagulants.
* Discontinuation of [[birth control pill]]s if patient is taking prior to the embolism
* Smoking cessation for smokers

== References ==
[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
<references group="Windecker S, Stortecky S, Meier B. Paradoxical embolism. Journal of the American College of Cardiology. 2014 Jul 29;64(4):403-15." /> 
<references />

Paradoxical embolism

2020-06-12T05:58:53Z

Muhammad Haisum Maqsood: /* References */

{{SI}}

{{CMG}} {{Hira Rehman}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, cryptogenic stroke, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation . If dislodged into brain, it could cause end-organ ischemia depending on site of blockade e.g brain, kidney, gut, limb and/or heart etc.

== Etiology ==
It can occur from any condition with any condition with breach in a barrier between right and left sided circulation of heart. <ref name=":0" />The most common pre-existing conditions that results in mixing of arterial and venous blood and eventually lead to paradoxical embolism include:

# Patent Foramen Ovale
# Atrial Septal Defect
# Arteriovenous Shunts
# Ventricular Septal Defects

Factors that enhance clotting mechanism beyond physiological requirements elevate the risks of incidence of paradoxical embolism e.g. genetic disorders of hypercoagulation (factor V Leiden deficiency, anti-thrombin III deficiency, protein C and S deficiency), increased estrogen levels (pregnancies and use of oral contraceptive pills), immobilization (related to surgery or disability) and malignancies .
==Pathophysiology and Presentation==
The prerequisites for paradoxical embolism include presence of blood clot on the veins and their eventual bypass passage from venous to arterial blood systems through a breach in integrity of separating right and left sides of heart . When already present clot in form of deep vein thrombosis which is mostly in veins of lower extremities dislodges, it traverses through the right side to the left side of heart and eventually through systemic circulation lodges in end-artery. The manifestation of symptoms depend on size of clot and vessels blocked. The most commonly blocked vessels include:

#Cerebral Arteries (leading to stroke)
#Mesenteric Arteries (leading to acute or chronic mesenteric ischemia)
#Femoral Artery (limb ischemic)
#Renal Artery (renal infarction)
#Coronary Artery (acute myocardial infarction)

==Differential Diagnoses==

# Deep vein thrombosis
# Endocarditis
# Atrial fibrillation leading to clot formation

==Diagnosis==
Paradoxical embolism is a diagnosis of exclusion which needs extensive laboratory work up to exclude other causes of possible symptoms manifestation. However, three conditions are required to meet clinical diagnosis <ref name=":1" />:

# Venous source of embolism
# Presence of intracardiac shunt or pulmonary fistula
# Arterial blockage

For detection of hypercoagulability, factor V Leiden assays and levels of anti-thrombin III, protein C and S are required.

Specialized studies for detection of intra-cardiac shunts include:

'''''Echocardiography'''''

Transthoracic and tranesophageal echocardiographies could be used for detection of intra-cardiac shunt anomalies. Due to non-invasive nature of transthoracic echocardiography, it is mostly used. This method is mostly used for detection of site and size of intra-cardiac defect .

Bubble study using echocardiography could be used for detection of small intra-cardiac defects. Saline with bubbles is injected through peripheral veins and the detection of bubbles on left side of heart through echocardiogram confirms the presence of intra-cardiac defect <ref>{{Cite journal|last=|first=Goutman SA, Katzan IL, Gupta R|date=2013|title=Transcranial Doppler with Bubble Study as a Method to Detect Extracardiac Right‐to‐Left Shunts in Patients with Ischemic Stroke|url=https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1552-6569.2012.00738.x|journal=Journal of Neuroimaging|volume=23|pages=523-25|via=}}</ref>.

'''''Transcranial Doppler Sonography'''''

This method is traditionally used for detection of right-to-left cardiac shunts in conjunction with transesophageal echocardiography. Contrast saline with bubbles is injected in venous blood and patient is also to do Valsalva maneuver <ref name=":2">{{Cite journal|last=|first=Chimowitz MI, Nemec JJ, Marwick TH, Lorig RJ, Furlan AJ, Salcedo EE|date=1991|title=Transcranial Doppler ultrasound identifies patients with right‐to‐left cardiac or pulmonary shunts|url=https://n.neurology.org/content/41/12/1902.short|journal=Neurology|volume=41|pages=|via=}}</ref>. Detection of microemboli in middle cerebral vessel through transcranial doppler sonography in conjunction with evidence of intra-cardiac defect via transesophageal echocardiography confirms the presence of defect <ref name=":2" />.

'''''Computed Tomography Resonance'''''

It produced a high resolution imaging of cardiac structure and its vasculature with high sensitivity and specificity <ref name=":3">{{Cite journal|last=et al|first=Williamson EE, Kirsch J, Araoz PA|date=2008|title=ECG-gated cardiac CT angiography using 64-MDCT for detection of patent foramen ovale|url=https://www.ajronline.org/doi/full/10.2214/AJR.07.3140|journal=American Journal of Roentgenology|volume=190|pages=929-33|via=}}</ref>. However, it's not commonly used as it could potentially damage heart with exposure to ionizing radiations<ref name=":3" />. Further, it could not evaluate functional aspects.
==Management==
'''Acute management''' of paradoxical embolism is dependent on specific organ involvement. Generally, the aim is to remove clot to avoid irreversible damage to organs. If cranial and coronary vasculature are involved, patients are treated on basis of stroke and acute myocardial infarction management guidelines, respectively.

'''Secondary Prevention''' aims at risk factors that lead to formation of clots and their passage through intra-cardiac shunts.

* Aspirin, an oral anticoagulant, is used to prevent formation of clots.
* Percutaneous closure of intracardiac shunt (closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]) is an outpatient procedure with minimal complications. Surgical Closure of intracardiac shunts is associated with operation related complications.
* Placement of a [[inferior vena cava]] ([[IVC]]) filter in patients with recurrent lower extremity deep vein thrombosis and contraindicated to anti-coagulants.
* Discontinuation of [[birth control pill]]s if patient is taking prior to the embolism
* Smoking cessation for smokers

== References ==
[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
<references group="Windecker S, Stortecky S, Meier B. Paradoxical embolism. Journal of the American College of Cardiology. 2014 Jul 29;64(4):403-15." /> 
<references />

Paradoxical embolism

2020-06-12T05:48:21Z

Muhammad Haisum Maqsood: /* References */

{{SI}}

{{CMG}} {{Hira Rehman}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, cryptogenic stroke, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation <ref name=":0">{{Cite journal|last=|first=Windecker S, Stortecky S, Meier B|date=2014|title=Paradoxical Embolism|url=https://www.ahajournals.org/doi/full/10.1161/circulationaha.110.961920|journal=Journal of American College of Cardiology|volume=64|pages=403-15|via=}}</ref>. If dislodged into brain, it could cause end-organ ischemia depending on site of blockade e.g brain, kidney, gut, limb and/or heart etc.

== Etiology ==
It can occur from any condition with any condition with breach in a barrier between right and left sided circulation of heart. <ref name=":0" />The most common pre-existing conditions that results in mixing of arterial and venous blood and eventually lead to paradoxical embolism include:

# Patent Foramen Ovale
# Atrial Septal Defect
# Arteriovenous Shunts
# Ventricular Septal Defects

Factors that enhance clotting mechanism beyond physiological requirements elevate the risks of incidence of paradoxical embolism e.g. genetic disorders of hypercoagulation (factor V Leiden deficiency, anti-thrombin III deficiency, protein C and S deficiency), increased estrogen levels (pregnancies and use of oral contraceptive pills), immobilization (related to surgery or disability) and malignancies <ref>{{Cite book|title=Paradoxical Embolism|last=|first=Hakman EN, Cowling KM|publisher=Treasure Island (FL): StatPearls Publishing|year=2020|isbn=|location=Florida|pages=}}</ref>.
==Pathophysiology and Presentation==
The prerequisites for paradoxical embolism include presence of blood clot on the veins and their eventual bypass passage from venous to arterial blood systems through a breach in integrity of separating right and left sides of heart <ref name=":1">{{Cite web|url=https://emedicine.medscape.com/article/460607-overview|title=Paradoxical Embolism|last=|first=Igor A Laskowski|date=10/2/2018|website=Medscape|archive-url=|archive-date=|dead-url=|access-date=6/12/2020}}</ref>. When already present clot in form of deep vein thrombosis which is mostly in veins of lower extremities dislodges, it traverses through the right side to the left side of heart and eventually through systemic circulation lodges in end-artery. The manifestation of symptoms depend on size of clot and vessels blocked. The most commonly blocked vessels include:

#Cerebral Arteries (leading to stroke)
#Mesenteric Arteries (leading to acute or chronic mesenteric ischemia)
#Femoral Artery (limb ischemic)
#Renal Artery (renal infarction)
#Coronary Artery (acute myocardial infarction)

==Differential Diagnoses==

# Deep vein thrombosis
# Endocarditis
# Atrial fibrillation leading to clot formation

==Diagnosis==
Paradoxical embolism is a diagnosis of exclusion which needs extensive laboratory work up to exclude other causes of possible symptoms manifestation. However, three conditions are required to meet clinical diagnosis <ref name=":1" />:

# Venous source of embolism
# Presence of intracardiac shunt or pulmonary fistula
# Arterial blockage

For detection of hypercoagulability, factor V Leiden assays and levels of anti-thrombin III, protein C and S are required.

Specialized studies for detection of intra-cardiac shunts include:

'''''Echocardiography'''''

Transthoracic and tranesophageal echocardiographies could be used for detection of intra-cardiac shunt anomalies. Due to non-invasive nature of transthoracic echocardiography, it is mostly used. This method is mostly used for detection of site and size of intra-cardiac defect <ref>{{Cite journal|last=|first=Seiler C|date=|title=How should we assess patent foramen ovale?|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1768530/|journal=BMJ|volume=90|pages=1245-47|via=}}</ref>.

Bubble study using echocardiography could be used for detection of small intra-cardiac defects. Saline with bubbles is injected through peripheral veins and the detection of bubbles on left side of heart through echocardiogram confirms the presence of intra-cardiac defect.

'''''Transcranial Doppler Sonography'''''

This method is traditionally used for detection of right-to-left cardiac shunts in conjunction with transesophageal echocardiography. Contrast saline medium is injected in venous blood and patient is also to do Valsalva maneuver. Detection of microemboli in middle cerebral vessel through transcranial doppler sonography in conjunction with evidence of intra-cardiac defect via transesophageal echocardiography confirms the presence of defect.

'''''Computed Tomography Resonance'''''

It produced a high resolution imaging of cardiac structure and its vasculature with high sensitivity and specificity. However, it's not commonly used as it could potentially damage heart with exposure to ionizing radiations. Further, it could not evaluate functional aspects.
==Management==
'''Acute management''' of paradoxical embolism is dependent on specific organ involvement. Generally, the aim is to remove clot to avoid irreversible damage to organs. If cranial and coronary vasculature are involved, patients are treated on basis of stroke and acute myocardial infarction management guidelines, respectively.

'''Secondary Prevention''' aims at risk factors that lead to formation of clots and their passage through intra-cardiac shunts.

* Aspirin, an oral anticoagulant, is used to prevent formation of clots.
* Percutaneous closure of intracardiac shunt (closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]) is an outpatient procedure with minimal complications. Surgical Closure of intracardiac shunts is associated with operation related complications.
* Placement of a [[inferior vena cava]] ([[IVC]]) filter in patients with recurrent lower extremity deep vein thrombosis and contraindicated to anti-coagulants.
* Discontinuation of [[birth control pill]]s if patient is taking prior to the embolism
* Smoking cessation for smokers

== References ==
[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
<references group="Windecker S, Stortecky S, Meier B. Paradoxical embolism. Journal of the American College of Cardiology. 2014 Jul 29;64(4):403-15." />Windecker S, Stortecky S, Meier B. Paradoxical embolism. JACC. 2014;64(4):403-15.

Paradoxical embolism

2020-06-12T05:28:37Z

Muhammad Haisum Maqsood: /* Treatment */

{{SI}}

{{CMG}} {{Hira Rehman}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, cryptogenic stroke, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation. If dislodged into brain, it could cause end-organ ischemia depending on site of blockade e.g brain, kidney, gut, limb and/or heart etc.

== Etiology ==
It can occur from any condition with any condition with breach in a barrier between right and left sided circulation of heart. The most common pre-existing conditions that results in mixing of arterial and venous blood and eventually lead to paradoxical embolism include:

# Patent Foramen Ovale
# Atrial Septal Defect
# Arteriovenous Shunts
# Ventricular Septal Defects

Factors that enhance clotting mechanism beyond physiological requirements elevate the risks of incidence of paradoxical embolism e.g. genetic disorders of hypercoagulation (factor V Leiden deficiency, anti-thrombin III deficiency, protein C and S deficiency), increased estrogen levels (pregnancies and use of oral contraceptive pills), immobilization (related to surgery or disability) and malignancies.
==Pathophysiology and Presentation==
The prerequisites for paradoxical embolism include presence of blood clot on the veins and their eventual bypass passage from venous to arterial blood systems through a breach in integrity of separating right and left sides of heart. When already present clot in form of deep vein thrombosis which is mostly in veins of lower extremities dislodges, it traverses through the right side to the left side of heart and eventually through systemic circulation lodges in end-artery. The manifestation of symptoms depend on size of clot and vessels blocked. The most commonly blocked vessels include:

#Cerebral Arteries (leading to stroke)
#Mesenteric Arteries (leading to acute or chronic mesenteric ischemia)
#Femoral Artery (limb ischemic)
#Renal Artery (renal infarction)
#Coronary Artery (acute myocardial infarction)

==Differential Diagnoses==

# Deep vein thrombosis
# Endocarditis
# Atrial fibrillation leading to clot formation

==Diagnosis==
Paradoxical embolism is a diagnosis of exclusion which needs extensive laboratory work up to exclude other causes of possible symptoms manifestation. However, three conditions are required to meet clinical diagnosis:

# Venous source of embolism
# Presence of intracardiac shunt or pulmonary fistula
# Arterial blockage

For detection of hypercoagulability, factor V Leiden assays and levels of anti-thrombin III, protein C and S are required.

Specialized studies for detection of intra-cardiac shunts include:

'''''Echocardiography'''''

Transthoracic and tranesophageal echocardiographies could be used for detection of intra-cardiac shunt anomalies. Due to non-invasive nature of transthoracic echocardiography, it is mostly used. This method is mostly used for detection of site and size of intra-cardiac defect.

Bubble study using echocardiography could be used for detection of small intra-cardiac defects. Saline with bubbles is injected through peripheral veins and the detection of bubbles on left side of heart through echocardiogram confirms the presence of intra-cardiac defect.

'''''Transcranial Doppler Sonography'''''

This method is traditionally used for detection of right-to-left cardiac shunts in conjunction with transesophageal echocardiography. Contrast saline medium is injected in venous blood and patient is also to do Valsalva maneuver. Detection of microemboli in middle cerebral vessel through transcranial doppler sonography in conjunction with evidence of intra-cardiac defect via transesophageal echocardiography confirms the presence of defect.

'''''Computed Tomography Resonance'''''

It produced a high resolution imaging of cardiac structure and its vasculature with high sensitivity and specificity. However, it's not commonly used as it could potentially damage heart with exposure to ionizing radiations. Further, it could not evaluate functional aspects.
==Management==
'''Acute management''' of paradoxical embolism is dependent on specific organ involvement. Generally, the aim is to remove clot to avoid irreversible damage to organs. If cranial and coronary vasculature are involved, patients are treated on basis of stroke and acute myocardial infarction management guidelines, respectively.

'''Secondary Prevention''' aims at risk factors that lead to formation of clots and their passage through intra-cardiac shunts.

* Aspirin, an oral anticoagulant, is used to prevent formation of clots.
* Percutaneous closure of intracardiac shunt (closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]) is an outpatient procedure with minimal complications. Surgical Closure of intracardiac shunts is associated with operation related complications.
* Placement of a [[inferior vena cava]] ([[IVC]]) filter in patients with recurrent lower extremity deep vein thrombosis and contraindicated to anti-coagulants.
* Discontinuation of [[birth control pill]]s if patient is taking prior to the embolism
* Smoking cessation for smokers

== References ==
[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
<references />

Paradoxical embolism

2020-06-12T05:07:08Z

Muhammad Haisum Maqsood: /* Etiology */

Paradoxical embolism

2020-06-12T05:04:39Z

Muhammad Haisum Maqsood: /* Differential Diagnoses */

{{SI}}

{{CMG}} {{Hira Rehman}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, cryptogenic stroke, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation. If dislodged into brain, it could cause end-organ ischemia depending on site of blockade e.g brain, kidney, gut, limb and/or heart etc.

== Etiology ==
It can occur from any condition with any condition with breach in a barrier between right and left sided circulation of heart. The most common pre-existing conditions that results in mixing of arterial and venous blood and eventually lead to paradoxical embolism include:

''1) Patent Foramen Ovale''

''2) Atrial Septal Defect''

''3) Arteriovenous Shunts''

''4) Ventricular Septal Defects''

Factors that enhance clotting mechanism beyond physiological requirements elevate the risks of incidence of paradoxical embolism e.g. genetic disorders of hypercoagulation (factor V Leiden deficiency, anti-thrombin III deficiency, protein C and S deficiency), increased estrogen levels (pregnancies and use of oral contraceptive pills), immobilization (related to surgery or disability) and malignancies.
==Pathophysiology and Presentation==
The prerequisites for paradoxical embolism include presence of blood clot on the veins and their eventual bypass passage from venous to arterial blood systems through a breach in integrity of separating right and left sides of heart. When already present clot in form of deep vein thrombosis which is mostly in veins of lower extremities dislodges, it traverses through the right side to the left side of heart and eventually through systemic circulation lodges in end-artery. The manifestation of symptoms depend on size of clot and vessels blocked. The most commonly blocked vessels include:

#Cerebral Arteries (leading to stroke)
#Mesenteric Arteries (leading to acute or chronic mesenteric ischemia)
#Femoral Artery (limb ischemic)
#Renal Artery (renal infarction)
#Coronary Artery (acute myocardial infarction) 

==Differential Diagnoses==

# Deep vein thrombosis
# Endocarditis
# Atrial fibrillation leading to clot formation

==Diagnosis==
Paradoxical embolism is a diagnosis of exclusion which needs extensive laboratory work up to exclude other causes of possible symptoms manifestation. However, three conditions are required to meet clinical diagnosis:

# Venous source of embolism
# Presence of intracardiac shunt or pulmonary fistula
# Arterial blockage

For detection of hypercoagulability, factor V Leiden assays and levels of anti-thrombin III, protein C and S are required.

Specialized studies for detection of intra-cardiac shunts include:

'''''Echocardiography'''''

Transthoracic and tranesophageal echocardiographies could be used for detection of intra-cardiac shunt anomalies. Due to non-invasive nature of transthoracic echocardiography, it is mostly used. This method is mostly used for detection of site and size of intra-cardiac defect.

Bubble study using echocardiography could be used for detection of small intra-cardiac defects. Saline with bubbles is injected through peripheral veins and the detection of bubbles on left side of heart through echocardiogram confirms the presence of intra-cardiac defect.

'''''Transcranial Doppler Sonography'''''

This method is traditionally used for detection of right-to-left cardiac shunts in conjunction with transesophageal echocardiography. Contrast saline medium is injected in venous blood and patient is also to do Valsalva maneuver. Detection of microemboli in middle cerebral vessel through transcranial doppler sonography in conjunction with evidence of intra-cardiac defect via transesophageal echocardiography confirms the presence of defect.

'''''Computed Tomography Resonance'''''

It produced a high resolution imaging of cardiac structure and its vasculature with high sensitivity and specificity. However, it's not commonly used as it could potentially damage heart with exposure to ionizing radiations. Further, it could not evaluate functional aspects. 
==Treatment==
Treatment of paradoxical embolization involves either:

*Closure of the defect in the heart( closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]))
*[[Anticoagulation]]
*Placement of a [[inferior vena cava]] ([[IVC]]) filter
*Discontinuation of [[birth control pill]]s
*Smoking cessation

== References ==
[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
<references />

Paradoxical embolism

2020-06-12T05:03:11Z

Muhammad Haisum Maqsood: /* Etiology */

{{SI}}

{{CMG}} {{Hira Rehman}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, cryptogenic stroke, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation. If dislodged into brain, it could cause end-organ ischemia depending on site of blockade e.g brain, kidney, gut, limb and/or heart etc.

== Etiology ==
It can occur from any condition with any condition with breach in a barrier between right and left sided circulation of heart. The most common pre-existing conditions that results in mixing of arterial and venous blood and eventually lead to paradoxical embolism include:

''1) Patent Foramen Ovale''

''2) Atrial Septal Defect''

''3) Arteriovenous Shunts''

''4) Ventricular Septal Defects''

Factors that enhance clotting mechanism beyond physiological requirements elevate the risks of incidence of paradoxical embolism e.g. genetic disorders of hypercoagulation (factor V Leiden deficiency, anti-thrombin III deficiency, protein C and S deficiency), increased estrogen levels (pregnancies and use of oral contraceptive pills), immobilization (related to surgery or disability) and malignancies.
==Pathophysiology and Presentation==
The prerequisites for paradoxical embolism include presence of blood clot on the veins and their eventual bypass passage from venous to arterial blood systems through a breach in integrity of separating right and left sides of heart. When already present clot in form of deep vein thrombosis which is mostly in veins of lower extremities dislodges, it traverses through the right side to the left side of heart and eventually through systemic circulation lodges in end-artery. The manifestation of symptoms depend on size of clot and vessels blocked. The most commonly blocked vessels include:

#Cerebral Arteries (leading to stroke)
#Mesenteric Arteries (leading to acute or chronic mesenteric ischemia)
#Femoral Artery (limb ischemic)
#Renal Artery (renal infarction)
#Coronary Artery (acute myocardial infarction)

 
==Differential Diagnoses==
Deep vein thrombosis

Endocarditis

Atrial fibrillation leading to clot

==Diagnosis==
Paradoxical embolism is a diagnosis of exclusion which needs extensive laboratory work up to exclude other causes of possible symptoms manifestation. However, three conditions are required to meet clinical diagnosis:

# Venous source of embolism
# Presence of intracardiac shunt or pulmonary fistula
# Arterial blockage

For detection of hypercoagulability, factor V Leiden assays and levels of anti-thrombin III, protein C and S are required.

Specialized studies for detection of intra-cardiac shunts include:

'''''Echocardiography'''''

Transthoracic and tranesophageal echocardiographies could be used for detection of intra-cardiac shunt anomalies. Due to non-invasive nature of transthoracic echocardiography, it is mostly used. This method is mostly used for detection of site and size of intra-cardiac defect.

Bubble study using echocardiography could be used for detection of small intra-cardiac defects. Saline with bubbles is injected through peripheral veins and the detection of bubbles on left side of heart through echocardiogram confirms the presence of intra-cardiac defect.

'''''Transcranial Doppler Sonography'''''

This method is traditionally used for detection of right-to-left cardiac shunts in conjunction with transesophageal echocardiography. Contrast saline medium is injected in venous blood and patient is also to do Valsalva maneuver. Detection of microemboli in middle cerebral vessel through transcranial doppler sonography in conjunction with evidence of intra-cardiac defect via transesophageal echocardiography confirms the presence of defect.

'''''Computed Tomography Resonance'''''

It produced a high resolution imaging of cardiac structure and its vasculature with high sensitivity and specificity. However, it's not commonly used as it could potentially damage heart with exposure to ionizing radiations. Further, it could not evaluate functional aspects. 
==Treatment==
Treatment of paradoxical embolization involves either:

*Closure of the defect in the heart( closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]))
*[[Anticoagulation]]
*Placement of a [[inferior vena cava]] ([[IVC]]) filter
*Discontinuation of [[birth control pill]]s
*Smoking cessation

== References ==
[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
<references />

Paradoxical embolism

2020-06-12T04:51:37Z

Muhammad Haisum Maqsood: /* Diagnosis */

Paradoxical embolism

2020-06-12T04:45:21Z

Muhammad Haisum Maqsood: /* Diagnosis */

Paradoxical embolism

2020-06-12T04:38:52Z

Muhammad Haisum Maqsood: /* Diagnosis */

Paradoxical embolism

2020-06-12T04:22:48Z

Muhammad Haisum Maqsood: /* Diagnosis */

Paradoxical embolism

2020-06-12T04:05:29Z

Muhammad Haisum Maqsood: /* Pathophysiology */

Paradoxical embolism

2020-06-12T03:38:26Z

Muhammad Haisum Maqsood: /* Historical Perspective */

Paradoxical embolism

2020-05-17T16:35:15Z

Muhammad Haisum Maqsood: /* Overview */

{{SI}}

{{CMG}}

'''''Synonyms and keywords:''''' Paradoxical embolization, paradoxical embolus, cryptogenic stroke, crossed embolism

==Overview==
A '''paradoxical embolism''' refers to a phenomenon of dislodging a clot from venous vasculature which traverses through intracardiac or intrapulmonary shunt into systemic circulation. If dislodged into brain, it could cause ischemic stroke with neurological manifestations depending on the site of blockade of intracranial arteries.

==Pathophysiology==
Paradoxical embolism involves passage of a venous clot (thrombus) from a vein to an artery. When clots in veins break off (embolize), they travel first to the right side of the heart and, normally, then to the lungs where they lodge, causing [[pulmonary embolism]]. On the other hand, when there is a hole in the wall between the two upper chambers of the heart (an [[atrial septal defect]]), a clot can cross from the right to the left side of the heart, then pass into the arteries as a paradoxical embolism. Once in the arterial circulation, a clot can travel to the brain, block a vessel there, and cause a stroke (cerebrovascular accident). The clot can lodge in the cerebral circulation, the coronary circulation, the mesenteric circulation, or in the circulation to a limb.

==Diagnosis==
Three conditions are required to meet clinical diagnosis:

1) Venous source of embolism

2) Presence of intracardiac shunt or pulmonary fistula

3) Arterial Embolism

=== Echocardiography===
A bubble study can be useful in establishing the presence of right-to-left shunting in the evaluation of the patient with suspected paradoxical embolism. It should be noted that bidirectional shunting can also be associated with paradoxical embolism.

==Treatment==
Treatment of paradoxical embolization involves either:

*Closure of the defect in the heart( closure of an [[atrial septal defect]] ([[ASD]]), [[ventricular septal defect]] ([[VSD]]), or [[patent foramen ovale]] ([[PFO]]))
*[[Anticoagulation]]
*Placement of a [[inferior vena cava]] ([[IVC]]) filter
*Discontinuation of [[birth control pill]]s
*Smoking cessation

[[Category:Cardiology]]
[[Category:Neurology]]
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}

How to create a user page

2020-05-01T17:17:19Z

Muhammad Haisum Maqsood: /* Current Position */

==What is a user page?==
Every user account on WikiDoc has an identity page called the user page. This page serves as a way to introduce individual users to the editing community. Unlike most pages that have standard convention, this page is the one place you can express your creativity.

==How do I find my user page?==
Your user page can be accessed at the top right corner of every page. 
[[Image:Userpage.png]]

Your user page will have to be created by you. It is your choice what information you would like displayed. You have the ability to delete any information you do not want shared with the editing community.

==How can I personalize my user page?==
There are lots of ways you can personalize your page!
# You can [[Special:Upload|upload]] and add [[Help:Images and other Media|a picture of yourself]].
# You can add your professional background.
# You can add your educational background.
# You can add a brief biography about yourself.

Below is a template for how to code a user page for all of these. If you copy the code below and paste it to your page, you can replace the information with your own.

{| border="1" cellpadding="2" cellspacing="0"
|-
!What it looks like
!What you type
|- valign="top"
|__NOTOC__

==Your Name==
'''Muhammad Haisum Maqsood''', MD[[Image:Flag of None.svg.png|right|frame|100px]]

 Contact: 
Email: haisumbajwa@live.com
==Current Position==
*

Research Fellow

==Professional Background==

==Education==

Medical Degree (MD) from King Edward Medical University, Lahore, Pakistan
==Brief Biography==
 
|<pre><nowiki>
__NOTOC__
==Your Name==
'''Muhammad Haisum Maqsood, MD'''[[Image:NameofYourPicture.jpg|right|frame|100px]]
Title on WikiDoc
 Contact: 
Email: [mailto:haisumbajwa@live.com insertyournamehere@whateverserver.com] 

==Current Position==
* Your Role in WikiDoc (list chapters here) 

==Professional Background==

==Education==
Medical Degree (MD) from King Edward Medical University, Lahore, Pakistan

==Brief Biography==
</pre>
|}
At the top right click on 'edit source' to input the template.
[[Category:Help]]

How to create a user page

2020-05-01T17:15:02Z

Muhammad Haisum Maqsood: /* How can I personalize my user page? */

==What is a user page?==
Every user account on WikiDoc has an identity page called the user page. This page serves as a way to introduce individual users to the editing community. Unlike most pages that have standard convention, this page is the one place you can express your creativity.

==How do I find my user page?==
Your user page can be accessed at the top right corner of every page. 
[[Image:Userpage.png]]

Your user page will have to be created by you. It is your choice what information you would like displayed. You have the ability to delete any information you do not want shared with the editing community.

==How can I personalize my user page?==
There are lots of ways you can personalize your page!
# You can [[Special:Upload|upload]] and add [[Help:Images and other Media|a picture of yourself]].
# You can add your professional background.
# You can add your educational background.
# You can add a brief biography about yourself.

Below is a template for how to code a user page for all of these. If you copy the code below and paste it to your page, you can replace the information with your own.

{| border="1" cellpadding="2" cellspacing="0"
|-
!What it looks like
!What you type
|- valign="top"
|__NOTOC__

==Your Name==
'''Muhammad Haisum Maqsood''', MD[[Image:Flag of None.svg.png|right|frame|100px]]

 Contact: 
Email: haisumbajwa@live.com
==Current Position==
*

==Professional Background==

==Education==

Medical Degree (MD) from King Edward Medical University, Lahore, Pakistan
==Brief Biography==
 
|<pre><nowiki>
__NOTOC__
==Your Name==
'''Muhammad Haisum Maqsood, MD'''[[Image:NameofYourPicture.jpg|right|frame|100px]]
Title on WikiDoc
 Contact: 
Email: [mailto:haisumbajwa@live.com insertyournamehere@whateverserver.com] 

==Current Position==
* Your Role in WikiDoc (list chapters here) 

==Professional Background==

==Education==
Medical Degree (MD) from King Edward Medical University, Lahore, Pakistan

==Brief Biography==
</pre>
|}
At the top right click on 'edit source' to input the template.
[[Category:Help]]