A patient with multiple paradoxical emboli

We present a case report of simultaneous pulmonary emboli and paradoxical embolism to the cerebellum causing a stroke and severe ischemia to the left leg. This patient had risk factors for thromboembolic events that included autoimmune disease, cancer, and recent pelvic surgery. The presence of a perforate foramen ovale was suspected on his initial presentation and confirmed with echocardiography. For acute leg ischemia, this patient underwent emergent left common femoral embolectomy. The potential benefit of immediate anticoagulation had to be weighed against the risk of hemorrhagic transformation of his cerebellar stroke with possible compression of the fourth ventricle. In the end, full anticoagulation was delayed with interval placement of a retrievable inferior vena cava filter. This case illustrates the challenges faced in treating a patient with multiple paradoxical emboli.