Paradoxical embolism through PFO leading to stroke in a gunshot victim with IVC injury

A 23-year-old man presented to the emergency department with multiple gunshot wounds to the chest and abdomen, and was taken to the operating room emergently for exploratory laparotomy due to hemodynamic instability. The patient underwent inferior vena cava (IVC), bowel and ureter repair during the procedure, requiring massive amounts of blood products. The patient transferred to the surgical intensive care unit with a routine post-operative course for approximately the next 7 days before presenting with signs of stroke. The patient was diagnosed with deep vein thrombosis in IVC at the repair site on a follow-up venogram. Upon further work-up with echocardiography, the patient was determined to have a patent foramen ovale (PFO), with paradoxical embolism as the most likely cause of the stroke. We present this unusual case of a GSW leading to stroke due to embolism from a venous source through a PFO.