Surgical embolectomy for paradoxical cerebral embolism with massive pulmonary embolism

Strategies in Management of Pulmonary Embolism With Acute Ischemic Stroke: A Systematic Review

Pulmonary embolism (PE) and acute ischemic stroke (AIS) are serious conditions with high morbidity and mortality. In the USA, PE causes around 100,000 deaths annually, with higher incidence in males. AIS following PE occurs in 1-10% of cases and is a leading cause of death within 2 - 4 weeks post-stroke. Managing concurrent PE and AIS is complex due to the need for anticoagulation, which is contraindicated after thrombolysis for AIS. This review evaluates the impact of various PE treatments - anticoagulation, thrombolysis, and embolectomy - on mortality in patients with both conditions. Following PRISMA 2020 guidelines, a systematic review was conducted across six databases from January 2010 to December 2023. The primary outcome measured was mortality, comparing treated vs. untreated patients for PE. Secondary outcomes included marked symptom improvement, slight improvement or deterioration of symptoms, and the complications. Data were analyzed descriptively, summarizing patient demographics, clinical characteristics, and treatment outcomes. Treatment modalities, such as anticoagulation, thrombolysis, catheter-directed thrombectomy, surgical thrombectomy, and conservative management, were evaluated based on their impact on symptom improvement, survival, and mortality. Initial querying of six databases yielded 1,679 articles, with only 21 remaining after a thorough review. Thrombolysis led to 100% symptom improvement and survival, with 0% mortality. Anticoagulation resulted in symptom improvement and survival in 62.5% of cases, with a 12.5% mortality rate. Catheter-directed and surgical thrombectomy had symptom improvement and survival in 66.7% and 75% of cases, respectively, with no mortality. Conservative management, defined here as management without anticoagulation or thrombolytic therapy, was associated with symptom worsening or no improvement and 50% mortality. This systematic review, based on observational data from case reports, highlights the diverse strategies used by physicians. Proactive and aggressive treatments, especially thrombolysis, show better outcomes and lower mortality rates. However, specific recommendations cannot be made from these results alone, emphasizing the need for well-designed prospective, randomized controlled trials to design structured guidelines for healthcare providers.

Clinical conundrum: concomitant high-risk pulmonary embolism and acute ischemic stroke

High-risk PE can be complicated by the presence of a patent foramen ovale (PFO), which can lead to paradoxical systemic embolization, including cerebral embolism ultimately leading to acute ischemic stroke (AIS). Acute management is challenging given the competing benefits and risks of systemic thrombolysis. Herein, we aim to provide a review of clinical presentations, diagnostic findings, and treatment and outcome from the available literature, with the hopes of providing insight into treatment options. We followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic literature search using PubMed/MEDLINE database, Cochrane Library, and Google Scholar for all reported cases/case series of concomitant high-risk PE and paradoxical ischemic stroke was conducted from inception to July 2019. Twenty-nine cases from 27 articles (26 single case reports, 1 case series of 3 patients) were included. There were 10 men and 19 women, ranging in age from 29 to 81 years (mean 56.1 ± 13.5 years). PFO was diagnosed in 89.7% of patients, mostly by transesophageal echocardiography. Treatment modalities included systemic thrombolysis (40%), anticoagulation alone (36%), surgical thrombectomy (16%), and percutaneous thrombectomy (8%). Overall mortality rate was 31%. Patients receiving thrombolysis and surgical thrombectomy had the most favorable outcome. Survival to discharge was 90% (9 out of 10), 100% (5 out of 5), and 50% (4 out of 8) in the systemic thrombolysis, surgical thrombectomy, and anticoagulation alone groups respectively. In the setting of combined high-risk PE and ischemic stroke, PFO can be detected in 90% of published cases. Thrombolysis and surgical thrombectomy seem to be effective management, but further studies are needed for validation.