Emergency Medicine Attending Summa Health System, United States
Introduction: Thromboembolic events are known to cause significant morbidity and mortality. Rarely, paradoxical stroke can occur with pulmonary embolism (PE) in the presence of a patent foramen ovale (PFO). These cases are complex because thrombolytic therapy is the treatment of choice for PE with hemodynamic instability; however, the risk of intracerebral hemorrhage after thrombolytic administration has been shown to increase after the five-hour mark from onset of stroke symptoms. We present a case of concurrent PE and paradoxical stroke that were treated with dual thrombectomies.
Description: A 50-year-old female was admitted for a right middle cerebral artery (MCA) stroke with a National Institutes of Health Stroke Scale (NIHSS) of 24. The time of last known well was nine hours prior to arrival. Thrombectomy was planned, but the patient had an episode of oxygen desaturation and was intubated. Bilateral upper lobe pulmonary emboli were visualized on the CTA head and neck. Cerebral thrombectomy proceeded with further workup of the pulmonary emboli to follow. While the cerebral thrombectomy was in process, the patient became unstable. Bedside echocardiogram revealed positive McConnell sign. CTA chest showed large bilateral PE's. Thrombolytics were contraindicated due to the right MCA stroke. Pulmonary artery thrombectomy was successful, and a heparin drip was started. The patient was extubated without complication. Duplex of the lower extremities demonstrated left popliteal DVT. Apixaban was initiated on discharge, and echocardiogram showed the presence of a PFO. NIHSS at time of discharge was at her pre-admission baseline of 1.
Discussion: Mechanical thrombectomy is an effective procedure for the treatment of both pulmonary embolism and ischemic stroke with large vessel occlusion. To our knowledge, this is the first description of dual mechanical thrombectomy to treat massive PE with concurrent stroke. While this diagnosis is rare, it poses unique challenges as fibrinolytics are indicated for massive PE but pose an increased risk of intracranial hemorrhage in the setting of ongoing ischemic stroke. Dual mechanical thrombectomy may be a feasible solution in thrombectomy-capable centers, but due to the rarity of the condition, data on the efficacy and safety profile will be difficult to obtain.
