Superior vena cava thrombosis and paradoxical embolic stroke due to collateral drainage from the brachiocephalic vein to the left atrium.

Abstract

Thrombosis involving a permanent infusion catheter in the subclavian vein and superior vena cava is relatively common, especially in cancer patients. Edema of the arms and head is a well-known clinical consequence of this thrombosis, with an intrinsic risk of pulmonary embolism; however, systemic embolization into the cerebral circulation has not been reported as a sequela. Herein, we describe the case of a 56-year-old man with metastatic prostate cancer who developed superior vena cava syndrome due to extensive thrombosis in the presence of a central venous catheter that was used for long-term chemotherapy. The patient's case was complicated by a cerebrovascular accident that was most likely caused by a paradoxical air embolism. A clear mechanism for the embolism was provided by a network of collateral veins, which developed between the brachiocephalic vein and the left atrium due to the superior vena cava obstruction and resulted in a right-to-left shunt. We discuss diagnosis and treatment of the condition in our patient and in general terms.