Question:

Which of the following criteria is not required for a paradoxical embolus?
1. A thrombus originating in the venous circulation.
2. An abnormal communication between right and left circulations.
3. Evidence of systemic embolism.
4. A favorable pressure gradient for thrombus to travel from right to left sided circulation through the abnormal communication.
5. The thrombus should be >10 mm in diameter.





Answer:

The correct answer for the question "Which of the following criteria is not required for a paradoxical embolus?" is:

5. The thrombus should be >10 mm in diameter.



Explanation
[Paradoxical embolism [4]is characterized by systemic venous thrombosis and entrance of the thrombus into the systemic arterial circulation through a right to left shunt which could be intra-cardiac i.e. patent foramen ovale (PFO), atrial septal defect (ASD), ventricular septal defect (VSD)or extra-cardiac i.e. pulmonary arteriovenous (AV) fistula]]



From the manuscript:
Large serpiginous thrombus straddling the patent foramen ovale and traversing through mitral and tricuspid valves into both ventricles: a therapeutic dilemma of impending paradoxical embolism and recurrent pulmonary embolism.
Radiology Case. 2014 Jul; 8(7):1-13


This article belongs to the Cardiac section.




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From the manuscript

Large serpiginous thrombus straddling the patent foramen ovale and traversing through mitral and tricuspid valves into both ventricles: a therapeutic dilemma of impending paradoxical embolism and recurrent pulmonary embolism.

Free full text article: Large serpiginous thrombus straddling the patent foramen ovale and traversing through mitral and tricuspid valves into both ventricles: a therapeutic dilemma of impending paradoxical embolism and recurrent pulmonary embolism.

Abstract
A 51-year-old male with history of resected renal cell carcinoma and prior pulmonary embolism presented with tachypnea, tachycardia and progressive dyspnea on exertion. Chest computed tomography revealed bilateral acute pulmonary embolism. Transthoracic echocardiogram showed severe pulmonary hypertension with severe cor-pulmonale and presence of a large worm-like thrombus extending across the foramen ovale, entering both ventricles through the mitral and tricuspid valves. The risks of anti-coagulation, pharmacologic thrombolysis, and surgical thrombectomy, in a hemodynamically stable patient, posed a significant therapeutic dilemma. Ultimately, a collective decision was made to start anticoagulation, without incident. At 1 month follow up, complete resolution of the intracardiac thrombus, pulmonary hypertension, and cor-pulmonale were observed with full clinical recovery of the patient.






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