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A 59 year old woman, 12 days after haematoma evacuation for hypertensive right putaminal haemorrhage, suddenly complained of dyspnoea and then collapsed just after she had started to walk. She was admitted to our hospital after cardiopulmonary resuscitation. On admission, the patient was in stable haemodynamic condition. She had a left hemiparesis and was slightly dyspnoeic, and had a Glasgow coma score of 15. Transthoracic echocardiography revealed right ventricular dilatation and floating structures in the right atrium, but the interatrial septum could not be clearly seen. Transoesophageal echocardiography revealed a large, snake-like structure crossing the foramen ovale of her interatrial septum. Each part of the structure in the right and left atrium was floating (top left panel: LA, left atrium: RA, right atrium). Unfortunately, despite the urgency of the situation, anticoagulation treatment or surgical removal of the thrombus could not be performed because of the patient’s recent cerebral haemorrhage. She was scheduled for surgery 10 days after admission (22 days after the cerebral haematoma evacuation).
The patient showed no clinical signs following the pulmonary embolism or paradoxical systemic embolism in the days preceding the operation. On the day of planned surgery, transoesophageal echocardiography revealed no thrombi in any cardiac chambers (top right panel). Atrial–atrial shunt could not be detected by using colour Doppler echocardiography. Contrast right-to-left shunting was detected immediately after the right atrial opacification phase (bottom panel: A, precontrast injection; B and C, contrast right-to-left shunting was detected immediately after the right atrial opacification phase; SVC, superior vena cava). Clinically, there was no evidence of thromboembolism. The patient was discharged after implantation of an inferior vena cava filter and is doing well without additional embolic events.