Stroke by paradoxical embolism after varicotomy

History and clinical findings: A 70-year-old woman developed an acute right -sided hemiparesis and global aphasia 10 days after saphenous vein strippin g of varicosities. Initially, she presented with somnolence, conjugated to the left, flexor synergism of the right extremities, exaggeration of knee a nd ankle jerks and extensor plantar responses on the right side. Investigations: 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 to mography then revealed a partial, mainly subcortical, infarction of the lef t middle cerbral artery territory. Doppler sonography revealed an occlusion of the left internal carotid artery. In duplex sonography there was no evi dence of arteriosclerosis. Transesoephageal echocardiography revealed a pat ent foramen ovate with right-to-left shunt. Treatment and course: immediately after admission intravenous anticoagulati on was initiated because of the suspected cardioembolic origin of the strok e. During hospitalization the global aphasia regressed and a continuing mob ilization was achieved while the right-sided hemiparesis persisted. The neu rological rehabilitation was initiated and continuous oral anticoagulation was planned. Conclusion: This case suggests a causal relationship between previously per formed vein stripping and paradoxical embolism resulting in a stroke. For p atients with patent foramen ovale, vein stripping may be associated with an increased stroke risk.