[Brain infarct from a paradoxical embolism following a varices operation]

A 70-year-old woman developed an acute right-sided hemiparesis and global aphasia 10 days after saphenous vein stripping of varicosities. Initially, she presented with somnolence, conjugated to the left, flexor synergism of the right extremities, exaggeration of knee and ankle jerks and extensor plantar responses on the right side.

The initial cranial computed tomography one hour after the onset of symptoms did not show reliable signs of cerebral ischaemia but a "dense artery sign" of the left middle cerebral artery. Repeat computed tomography then revealed a partial, mainly subcortical, infarction of the left middle cerebral artery territory. Doppler sonography revealed an occlusion of the left internal carotid artery. In duplex sonography there was no evidence of arteriosclerosis. Transesophageal echocardiography revealed a patent foramen ovale with right-to-left shunt.

Immediately after admission intravenous anticoagulation was initiated because of the suspected cardioembolic origin of the stroke. During hospitalization the global aphasia regressed and a continuing mobilization was achieved while the right-sided hemiparesis persisted. The neurological rehabilitation was initiated and continuous oral anticoagulation was planned.

This case suggests a causal relationship between previously performed vein stripping and paradoxical embolism resulting in a stroke. For patients with patent foramen ovale, vein stripping may be associated with an increased stroke risk.