Paradoxical Stroke via Persistent Levoatriocardinal Vein and Evaluation and Management Recommendations

The levoatriocardinal vein (LACV) is a cardiac anomaly that may cause right-to-left shunts and paradoxical embolic stroke. To date, there are no guidelines for management of this phenomenon.

An 80-year-old man with a history of Parkinson disease, dementia, and prostate cancer presented to the hospital with new right-sided weakness and aphasia. Computed tomography angiogram of the head and neck demonstrated occlusion of the left middle cerebral artery, and he underwent endovascular thrombectomy. Brain magnetic resonance imaging revealed acute bilateral infarcts in multiple vascular territories suggesting an embolic source. A transthoracic echocardiogram with agitated saline showed opacification of the left atrium and ventricle. Cardiac computed tomography showed an LACV draining into the left superior pulmonary vein. An upper extremity venous Doppler ultrasound revealed deep venous thrombus in the left cephalic vein, which was considered the likely source of the embolic stroke. The patient was discharged on lifelong anticoagulation, without stroke recurrence.

This case illustrates the importance of multimodal imaging in all patients with stroke.

All patients with stroke should obtain advanced imaging to characterize abnormal cardiac anatomy such as LACV. Management of LACV should be informed by the perceived benefit of treatment and patient risk factors.