A 64-year-old woman was admitted for acute abdominal pain, hematochezia and severe hypotension.
She reported migraine headaches since her adolescence and several unstudied episodes of dysarthria and non-vertigo instability, compatible with transient cerebral ischemia.
One patient developed ischemic colitis.
Cardiovascular evaluation, including electrocardiography and transthoracic echocardiography, did not detect arrhythmias or foci of embolism.
Pathological searches were negative.
A previous clinical observation led to the indication of a contralateral brain sound intensity (TSS) in the distribution of blood flow, and a continuous monitoring of four vessels from the left temporal window using M-mode Doppler, which was compatible with high spontaneous microboli.
An ultrasound of the lower limbs showed bilateral deep venous thrombosis as a potential source of paradoxical embolization and a TCD with injection of microbubbles confirmed the presence of a right-to-left shunt at rest.
Treatment with absolute diet, intravenous fluids, prophylactic anticoagulation with heparin and antiplatelet therapy with aspirin led to a favorable evolution of the patient in the next week, being referred for transesophageal echocardiography.
