A. Pai 1 , A.L. Riba 1 , R.D. Hobbs 1 ; 1 Oakwood Healthcare System, Dearborn, MI LEARNING OBJECTIVE: To recognize the unique radiologic and therapeutic features associated with impending paradoxical emboli. CASE INFORMATION: A 61 year old female presented with an acute onset of intractable headaches, vertigo, dyspnea and melena. A CT scan confirmed an embolic CVA involving the right occipital lobe. The presence of an asymptomatic, swollen right leg, and an acute axis change on EKG lead to the suspicion of a DVT with PE. Large thrombi were seen in both pulmonary arteries on spiral CT. Additionally, a TEE demonstrated a large embolus straddling a patent foramen ovale. Therapy was problematic due to the patient's history of complications following a CABG in the past and active GI bleeding. A conservative treatment approach involved careful anticoagulation with heparin and Greenfield filter placement. The patient success-fully recovered without further embolic episodes or complications. DISCUSSION: Although 25% of patients at autopsy have a patent foramen ovale that can be detected by probing, the actual occurrence of paradoxical emboli (as with most pulmonary emboli) can safely be assumed to be under-diagnosed. Although newer technology (spiral CT, TEE) has increased our ability to diagnose such conditions, impending paradoxical embolus is still rarely reported in the literature. The optimal therapy is unknown although embolectomy with closure of the patent foramen ovale, thrombolysis and anticoagulation are the commonly available options. Treatment should be individualized depending on the patients age, existing co-morbidities and the availability of cardiothoracic surgical services.