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Brain abscess associated with an unusual cause of right to left shunt
  1. A Hirth,
  2. P Disney,
  3. S Thorne
  1. ahir{at}

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A 33-year-old woman with a history of brain abscess 4 years earlier was admitted with an infected cranial bone flap requiring surgical debridement. Four days postoperatively she was found collapsed, presumed secondary to a seizure. She was resuscitated but developed severe aspiration pneumonia. Systemic pressures were recorded from a left internal jugular line, and a chest x ray (panel A) suggested that it had passed via a persistent left superior vena cava (SVC) into the left atrium and ventricle and into the ascending aorta. The diagnosis was confirmed by echocardiography: intravenous agitated saline contrast from the left arm showed immediate opacification of the left heart (panel B). She died from multiorgan failure 24 h later. Postmortem examination confirmed this isolated anomaly.

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Anteroposterior chest x ray showing central venous catheter (dotted line) emerging from the left internal jugular vein/persistent left superior vena cava, entering the left atrium, looping in the left ventricle with the tip in the ascending aorta. Ao, aorta; LA, left atrium; LV, left ventricle.

Right to left shunts predispose to cerebral abscess. A left SVC draining directly to the left atrium is a rare cause of right to left shunt (<5:100 000 of the general population).

This case highlights two very important clinical issues. Firstly, a brain abscess in the absence of an obvious precipitating cause should prompt a search for a right to left shunt with saline contrast echocardiography. Secondly, saline contrast studies should be performed from the left and not the right arm, to prevent overlooking a persistent left SVC to left atrium communication.

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Transthoracic echocardiography-modified apical four-chamber view showing dense left ventricle opacification only (white) following left arm intravenous agitated saline injection. LV, left ventricle, RA, right atrium; RV, right ventricle.


  • Competing interests: None.