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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1371-1373

Simultaneous Acute Pulmonary Thromboembolism and Stroke – A Management Dilemma

1 Department of Neurology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
2 Department of Critical Care Medicine, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India
3 Department of Cardiology, Krishna Institute of Medical Sciences, Secunderabad, Telangana, India

Date of Submission07-Oct-2020
Date of Decision08-Jul-2021
Date of Acceptance08-Aug-2021
Date of Web Publication30-Oct-2021

Correspondence Address:
Sita Jayalakshmi
Senior Consultant Neurologist, Krishna Institute of Medical Sciences, Minister Road, 1-8-31/1, Secunderabad, Hyderabad - 500 003, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.329553

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 » Abstract 

The management of established pulmonary thromboembolism (PTE) coexisting with acute ischemic stroke (AIS) is quite challenging. We report the case of a 52-year-old man with concurrent massive right middle cerebral artery AIS and acute PTE, who was successfully managed despite the contradictory guidelines to manage them simultaneously. The patient underwent decompression craniotomy followed by anticoagulant therapy. The current case report demonstrates that full-dose heparin, despite being relatively contraindicated in an AIS, can achieve a good outcome when given under close monitoring. The transesophageal echo with bubble contrast during the Valsalva maneuver demonstrated patent foramen ovale with a right to left shunt as a cause of AIS and PTE in this patient.

Keywords: Acute ischemic stroke, patent foramen ovale, pulmonary thromboembolism
Key Message: Full-dose heparin, despite being relatively contraindicated in an AIS, can help achieve a good outcome in patients of AIS and PTE when given under close monitoring.

How to cite this article:
Jayalakshmi S, Khandalia H, Vooturi S, Jiwani P A, Kaul S. Simultaneous Acute Pulmonary Thromboembolism and Stroke – A Management Dilemma. Neurol India 2021;69:1371-3

How to cite this URL:
Jayalakshmi S, Khandalia H, Vooturi S, Jiwani P A, Kaul S. Simultaneous Acute Pulmonary Thromboembolism and Stroke – A Management Dilemma. Neurol India [serial online] 2021 [cited 2022 May 25];69:1371-3. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1371/329553

Pulmonary thromboembolism (PTE) is one of the most feared complications of acute ischemic stroke (AIS); therefore, the current guidelines are focused toward its prevention in immobile stroke patients.[1],[2] However, taking treatment decisions in patients of AIS with established PTE can be quite challenging. We are reporting a case with concurrent AIS and acute PTE who was successfully managed despite the contradictory guidelines to manage them simultaneously.

 » Case Report Top

A 52-year-old man with complaints of sudden onset of left hemiplegia while straining to pass stools was brought to the emergency department. There was history of episodes of intermittent breathlessness with low-grade fever for one week preceding the admission. On examination, he was drowsy with a blood pressure of 90/60 mmHg, pulse rate of 120/min, and left hemiplegia. Diffusion weighed magnetic resonance imaging (MRI) of the brain revealed diffusion restriction in the entire right middle cerebral artery territory with thrombotic occlusion in the right M1 segment [Figure 1] and [Figure 2]. Complete blood examination and kidney and liver function tests were normal. A 12-lead electrocardiogram showed tachycardia and right ventricular (RV) strain pattern. Central venous pressure was >18 mmHg. Transthoracic echocardiogram (TTE) with saline bubble test revealed dilated right RA and diffuse RV hypokinesia. RA pressure of 27 mmHg with tricuspid regurgitation was suggestive of pulmonary hypertension. Computed tomography pulmonary angiogram revealed massive PTE involving bilateral pulmonary arteries extending into their ascending and descending branches including distal branches [Figure 3]. Lower limb doppler was negative for deep venous thrombosis. He was offered the options of catheter-directed thrombolysis (CdT) or suction thrombectomy (ST), but these could not be performed as both were beyond his affordability. Elective decompressive craniotomy was done on the second day of admission to prevent raised intracranial pressure. Prothrombotic conditions such as hyperhomocysteinemia, antinuclear antibody, and antiphospholipid antibody were excluded. Postoperatively, the patient continued to have breathlessness. Low molecular weight heparin (LMWH) in therapeutic dose was started at 24 hours post decompression. The patient was regularly monitored for an increase in the neurological deficit and signs of raised intracranial pressure. His neurological status gradually improved over the next 48 hours and he was able to communicate with family members. Pressure in RV normalized in the repeated TTE. After two weeks, the patient was switched over to Warfarin with a target pro-thrombin international normalized ratio (PT-INR) of 3, and given for six months. Transesophageal echocardiogram (TEE) in follow-up visit revealed patent foramen ovale (PFO) with right to left shunt on saline bubble test [Figure 4]. At 5 years follow-up, the patient is independent in activities of daily living with residual left hemiparesis.
Figure 1: DW MRI brain showing diffusion restriction in right MCA territory suggestive of acute infarct

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Figure 2: MR Angiogram demonstrating right MCA cut off (arrow)

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Figure 3: Bilateral massive PTE extending up to sub-segmental vessels

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Figure 4: TEE with color Doppler during Valsalva showing right to left shunt across patent foramen ovale

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 » Discussion Top

Although prophylactic anticoagulants in low doses have been recommended to prevent PTE in AIS,[1],[2],[3] the management of established PTE coexisting with AIS is quite challenging.[4],[5] Recommended treatment for massive PTE is fibrinolysis by plasminogen-activating fibrinolytic agents but is absolutely contraindicated in ischemic stroke within three months. The role of therapeutic heparinization for PTE early after a massive stroke is controversial because of the high risk of hemorrhagic transformation. AHA guidelines recommend against early therapeutic anticoagulation in patients with moderate to severe stroke while UK Stroke guidelines in a similar situation suggest anticoagulation for proximal DVT or PT even at the cost of increased intra- and extracranial hemorrhages.[1],[6] Depending on the availability of infrastructure, CdT or ST is a safer modality for treating PTE in patients with massive acute ischemic stroke.[7],[8],[9]

The risk-benefit analysis of our patient showed that while he had a big infarct potentially at risk for hemorrhagic transformation, he also had a potentially fatal PTE requiring treatment. In view of the risk of hemorrhagic transformation with heparinization, the patient was offered the options of CdT or ST, both of which were beyond his affordability. A review of the literature showed that of a cumulative 17 patients of PTE with AIS reported as case studies/series [Table 1], heparin was administered in 15 patients, with good outcomes in more than half of them.[7] Therefore, we opted for full-dose LMWH for two weeks followed by oral anticoagulation for six months.[12],[13],[14],[15],[16],[17],[18],[19],[20]
Table 1: Literature review - Outcome of patients with PTE with AIS treated with heparin

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Importantly, the simultaneous occurrence of AIS with PTE in the current patient was suggestive of intracardiac communication such as PFO. However, the uniqueness of our case report is that PFO was not observed in TTE with bubble contrast without any provocative measures. Therefore, we suggest that in patients with PTE with AIS, because the shunt across the PFO varies with pressure in the right atrial and pulmonary artery, TTE could be performed with provocative measures, resulting in raised right atrial pressure.[10],[11] Further interview of the patient for initial presentation revealed that straining to pass stools might have had transient elevated RA pressure opening the functional PFO, acting as a passage for thrombus and resulting in the massive ischemic stroke that required decompression.

To conclude, the current case report demonstrates that full-dose heparin, despite being relatively contraindicated in an AIS when given under close monitoring in this patient of AIS and PTE, results in a good outcome. In patients with PTE with AIS, because the shunt across the PFO varies with pressure in the right atrial and pulmonary artery, TTE could be performed with provocative measures such as the Valsalva maneuver.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Kelly J, Rudd A, Lewis R, Hunt BJ. Venous thromboembolism after acute stroke. Stroke 2001;32:262-7.  Back to cited text no. 1
Powers WJ, Rabinstein AA, Ackerson T. Guidelines for the early management of patients with acute Ischemic Stroke: 2019 Update to the 2018 guidelines for the early management of acute ischemic stroke. Stroke 2019;50:e344-418.  Back to cited text no. 2
Dennis M, Caso Vhehe Kappelle LJ, Pavlovic A, Sandercock P, European Stroke Organization. European Stroke Organization (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischemic stroke. Eur Stroke J 2016;1:6-19.  Back to cited text no. 3
Iskander A, Nayak A, Chauhan MS. Submassive pulmonary embolism and paradoxical embolic stroke treated with percutaneous rheolytic thrombectomy and closure of the patent foramen ovale. Catheter Cardiovasc Interv 2005;64:356-60.  Back to cited text no. 4
Concomitant submassive pulmonary embolism and paradoxical embolic stroke after a long flight: Which is the optimal treatment ? Cardiovasc Med 2008;9:1070-3.  Back to cited text no. 5
Swain S, Turner C, Tyrrell P, Rudd A, Guideline Development Group. Diagnosis and initial management of acute stroke and transient ischaemic attack: Summary of NICE guidance. BMJ 2008;337:a786.  Back to cited text no. 6
Condliffe R, Elliot CA, Hughes RJ, Hurdman J, Maclean RM, Sabroe I, et al. Management dilemmas in acute pulmonary embolism. Thorax 2014;69:174-8.  Back to cited text no. 7
Avgerinos ED, Abou Ali A, Toma C, Wu B, Saadeddin Z, McDaniel B, et al. Catheter-directed thrombolysis versus suction thrombectomy in the management of acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2019;7:623-8.  Back to cited text no. 8
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543-603.  Back to cited text no. 9
Reichenberger F, Kaps M, Seeger W, Tanislav C. Shunt volume dynamics in stroke patients with patent foramen ovale. J Appl Physiol (1985) 2013;115:704-7.  Back to cited text no. 10
Movsowitz C, Podolsky LA, Meyerowitz CB, Jacobs LE, Kotler MN. Patent foramen ovale: A nonfunctional embryological remnant or a potential cause of significant pathology? J Am Soc Echocardiogr 1992;5:259-70.  Back to cited text no. 11
Lapostolle F, Surget V, Borron SW, Desmaizières M, Sordelet D, Lapandry C, et al. Severe pulmonary embolism associated with air travel. N Engl J Med 2001;345:779-83.  Back to cited text no. 12
Belvís R, Masjuan J, García-Barragán N, Cocho D, Martí-Fàbregas J, Santamaría A, et al. Stroke and pulmonary thromboembolism after a long flight. Eur J Neurol 2005;12:732-4.  Back to cited text no. 13
Iwanaga T, Iguchi Y, Shibazaki K, Inoue T, Kimura K. Paradoxical brain embolism in an acute stroke. J Neurol Sci 2007;254:102-4.  Back to cited text no. 14
Allport LE, Butcher KS. Thrombolysis for concomitant acute stroke and pulmonary embolism. J Clin Neurosci 2008;15:917-20.  Back to cited text no. 15
Pavesi PC, Pedone C, Crisci M, Piacentini A, Fulvi M, Di Pasquale G. Concomitant submassive pulmonary embolism and paradoxical embolic stroke after a long flight: Which is the optimal treatment? J Cardiovasc Med (Hagerstown) 2008;9:1070-3.  Back to cited text no. 16
Pelletier M, Bugeaud R, Ibrahim R, Morency G, Kouz S. Successful thrombolysis of a stroke with a pulmonary embolism in a young woman. J Emerg Med 2010;39:443-8.  Back to cited text no. 17
Gunta S, Kamath S. A case of pulmonary embolism and stroke in a 16-year-old girl. WMJ 2012;111:58-60.  Back to cited text no. 18
Christiansen ME, Kumar G, Mahabir RC, Helmers RA, Bendok BR, O'Carroll CB. Intravenous alteplase for acute stroke and pulmonary embolism in a patient with recent abdominoplasty. Neurologist 2017;22:150-2.  Back to cited text no. 19
Saleh Velez FG, Ortiz Garcia JG. Management dilemmas in acute ischemic stroke and concomitant acute pulmonary embolism: Case series and literature review. eNeurologicalSci 2021;23:100341. doi: 10.1016/j.ensci.2021.100341.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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