We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Skip to main content

Advertisement

SpringerLink
Log in

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

  • Review Article
  • Published:
Emergency Radiology Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Kahn SR, Shbaklo H, Lamping DL, Holcroft CA, Shrier I, Miron MJ, Roussin A, Desmarais S, Joyal F, Kassis J, Solymoss S, Desjardins L, Johri M, Ginsberg JS (2008) Determinants of health-related quality of life during the 2 years following deep vein thrombosis. J Thromb Haemost 6:1105–1112

    Article  CAS  Google Scholar 

  2. Marshall PS, Mathews KS, Siegel MD (2011) Diagnosis and management of life-threatening pulmonary embolism. J Intensive Care Med 26:275–294

    Article  Google Scholar 

  3. Sekhri V, Mehta N (2012 Dec 20) Management of massive and nonmassive pulmonary embolism. Arch Med Sci 8(6):957–969

    Article  CAS  Google Scholar 

  4. Stulz P, Schlapfer R, Feer R et al (1994) Decision making in the surgical treatment of massive pulmonary embolism. Eur J Cardiothorac Surg 8:188–193

    Article  CAS  Google Scholar 

  5. Goliszek S, Wiśniewska M, Kurnicka K, Lichodziejewska B, Ciurzyński M, Kostrubiec M, Gołębiowski M, Babiuch M, Paczynska M, Koć M, Palczewski P, Wyzgał A, Pruszczyk P (2014) Patent foramen ovale increases the risk of acute ischemic stroke in patients with acute pulmonary embolism leading to right ventricular dysfunction. Thromb Res 134:1052–1056

    Article  CAS  Google Scholar 

  6. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): the task force for the diagnosis and management of acute pulmonary embolism of The European Society of Cardiology (ESC). Eur Respir J. 2019 Oct 9;54(3). pii: 1901647

  7. Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, Stevens SM, Vintch JRE, Wells P, Woller SC, Moores L. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report 2016 Feb;149(2):315–352

  8. Mathieu pelletier, ronald bugeaud, reda ibrahim, gilles morency, simon kouz, successful thrombolysis of a stroke with a pulmonary embolism in a young woman. J Emerg Med. 2010 Oct;39(4):443–8. doi: https://doi.org/10.1016/j.jemermed.2009.02.033. Epub 2009 Apr 3

  9. Barrios DD, Roncancio J, Avila AA, Alvarado JA, Montenegro AC (2017) Paradoxical embolism due to persistent foramen ovale; a case report. Emergency. 5(1):e46

    PubMed  PubMed Central  Google Scholar 

  10. Poobalan Naidoo and Richard Hift. Massive pulmonary thromboembolism and stroke. Case Rep Med. 2011;2011:398571. https://doi.org/10.1155/2011/398571. Epub 2011 Sep 28

  11. Delgado MG, Mauri G, Vega J (2012) Massive pulmonary thromboembolism after intravenous stroke thrombolysis. BMJ Case Rep. Mar 27;2012. pii: bcr1020115008. doi: https://doi.org/10.1136/bcr.10.2011.5008

  12. Hattori K, Daitoku K, Taniguchi S, Fukuda I (2019) Surgical embolectomy for paradoxical cerebral embolism with massive pulmonary embolism Gen Thorac Cardiovasc Surg Apr 6. doi: https://doi.org/10.1007/s11748-019-01087-6

  13. Bagate F, Bedet A, Dessap AM (2018) Guillaume Carteaux Paradoxical brain embolism shadowing massive pulmonary embolism. Am J Emerg Med 36(8):1527.e1–1527.e2. https://doi.org/10.1016/j.ajem.2018.05.024

    Article  Google Scholar 

  14. Dada R, Dada J, Abdelsalam M, Agrawal Y (2018) Thrombus straddling a patent foramen ovale, pulmonary embolism and paradoxical embolism: a rare trifecta. BMJ Case Rep. https://doi.org/10.1136/bcr-2018-227505

  15. Prevel R, Garco P, Philippart F (2015 Jan-Mar) An uncommon pulmonary embolism. Int J Crit Illn Inj Sci 5(1):50–52

    Article  Google Scholar 

  16. de Oliveira MAB, Sabbag AT, Brandi AC, dos Santos CA, Botelho PH, Patriarcha FA, Braile DM (2016 Sep-Oct) Surgical treatment for thrombus straddling a patent foramen Ovale. Braz J Cardiovasc Surg 31(5):406–408

    PubMed  PubMed Central  Google Scholar 

  17. Sattar A, Win TT, Schevchuck A, Achrekar A (2016) Extensive biatrial thrombus straddling the patent foramen ovale and traversing into the left and right ventricle BMJ Case Rep. 2016: bcr2016216761

  18. Hsu C-H, Chao T-H (2005 Sep) Intracardiac thrombosis in multiple chambers and descending aorta manifested as systemic and pulmonary thromboembolism. echocardiography 22(8):671–674

    Article  Google Scholar 

  19. Tournoux F, Logeart D, Cohen-Solal A (2006 Jan) Massive pulmonary embolism and stroke due to thrombus across the foramen ovale. Ann Cardiol Angeiol (Paris) 55(1):55–57

    Article  CAS  Google Scholar 

  20. Bracey TS, Langrish C, Darby M, Soar J (2006) Cerebral infarction following thrombolysis for massive pulmonary embolism. Resuscitation 68:135–137

    Article  Google Scholar 

  21. Supawon Srettabunjong, MD, LLB, MSc, MTox . Systemic thromboembolism after deep vein thrombosis caused by uterine myomas. Am J Forensic Med Pathol & Volume 34, Number 3, September 2013

  22. Reynaud Q, Catella J, Diconne E, Lafond P, Tardy B (2014 Jan) No surgery without previous compression ultrasound in patients with a superficial venous thrombosis: a case of massive paradoxical embolism. Ann Fr Anesth Reanim 33(1):41–43. https://doi.org/10.1016/j.annfar.2013.11.013 Epub 2013 Dec 22

  23. Park M-S, Park J-P, Yun S-H, Lee J-U, Kim J-K, Lee N-E, Song J-E, Lee S-E, John S-H, Lim J-H, Rhew J-Y (2012) A case of cryptogenic stroke associated with patent foramen ovale coexisting with pulmonary embolisms, deep vein thromboses, and renal artery infarctions. Korean Circ J 42:853–856

    Article  Google Scholar 

  24. Sibbing D, Overbeck M, Schmidt R, Gaa J, Barthel P (2006 Nov) Patent foramen ovale with a riding vermicular thrombus causing paradoxical and massive pulmonary embolism. Eur Heart J 27(22):2724 Epub 2006 Apr 27

  25. Uğurlu AÖ, Çınar Ö, Caymaz İ, Çevik H, Gümüş B (2015) Combined catheter thrombus fragmentation and percutaneous thrombectomy in a patient with massive pulmonary emboli and acute cerebral infarct. Anatolian J Cardiol 15:69–74

    Article  Google Scholar 

  26. Lio KU, Kumaran M, Rali P (2019 Nov-Dec) Patent foramen ovale: connecting dots from massive pulmonary embolism to acute ischemic stroke. Lung India 36(6):564–566

    Article  Google Scholar 

  27. Carlsson J, Miketic S, Kuhn A, Brune S, Tebbe U. Paradoxical cerebral emboli during thrombolysis of deep vein thrombosis and pulmonary emboli. Dtsch Med Wochenschr 1994 Feb 18;119(7):222–226

  28. Silméia Garcia Zanati Bazan, Gabriel Pereira Braga, Gustavo José Luvizutto, André Petean Trindade, Octávio Marques Pontes-Neto, and Rodrigo Bazan, Bihemispheric paradoxical cerebral embolism in a patient with pulmonary thromboembolism and presumptive fistula right-to-left shunt, Journal of Stroke and Cerebrovascular Diseases, Vol. 25, No. 6 (June), 2016: pp e95–e97

  29. Kirin M, Ceric R, Spoljaric M, Pehar M, Cavric G, Spoljaric IR, Kirin I (2008) The right atrial thrombus: the sword of damocles with real risk of massive pulmonary embolism. ANGIOLOGY 59:415

    Article  Google Scholar 

  30. Nam SB, Kim CM, Cho S-A, Chung S, Shim YH (2015) Thrombus entrapped by patent foramen ovale in a patient with pulmonary embolism: a case report. Korean J Anesthesiol 68:70–73

    Article  Google Scholar 

  31. Ashequl Islam M, Khalighi K, Goldstein JE, Raso J (2000) Paradoxical embolism—report of a case involving four organ systems. The Journal of Emergency Medicine 19(1):31–34

    Article  Google Scholar 

  32. Xiao-jie XIE, Ju-bo Jiang, Jun Jiang, Jian-an Wang (2014) Concurrent pulmonary thrombosis with systemic embolism: Case Report. Xie et al. / J Zhejiang Univ-Sci B (Biomed & Biotechnol) 15(9):838–844

  33. Mirarchi FL, Hecker J, Kramer CM (2000) Pulmonary embolism complicated by patent foramen ovale and paradoxical embolization. The Journal of Emergency Medicine 19(1):27–30

    Article  CAS  Google Scholar 

  34. Doorenbos D, Clifton R (1992) Problems in identifying paradoxical cerebral embolism: case report with discussion. J Stroke Cerebraoasc Dis 2:110–113

    Article  CAS  Google Scholar 

  35. Homma S, Sacco RL (2005) Patent foramen ovale and stroke. Circulation 112(7):1063e72

    Article  Google Scholar 

  36. Windecker S, Stortecky S, Meier B (2014 Jul 29) Paradoxical embolism. J Am Coll Cardiol 64(4):403–415. https://doi.org/10.1016/j.jacc.2014.04.063

    Article  PubMed  Google Scholar 

  37. Lewis-Carey MB1, Kee ST, Feinstein JA. Temporary IVC filtration before patent foramen ovale closure in a patient with paradoxic embolism. J Vasc Interv Radiol. 2002 Dec;13(12):1275–8

  38. Le Moigne E, Timsit S, Ben Salem D, Didier R, Jobic Y, Paleiron N, Le Mao R, Joseph T, Hoffmann C, Dion A, Rousset J, Le Gal G, Lacut K, Leroyer C, Mottier D, Couturaud F (2019 May 7) Patent foramen ovale and ischemic stroke in patients with pulmonary embolism: a prospective cohort study. Ann Intern Med. https://doi.org/10.7326/M18-3485

  39. Goliszek S, Wiśniewska M, Kurnicka K, Lichodziejewska B, Ciurzyński M, Kostrubiec M, Gołębiowski M, Babiuch M, Paczynska M, Koć M, Palczewski P, Wyzgał A, Pruszczyk P (2014 Nov) Patent foramen ovale increases the risk of acute ischemic stroke in patients with acute pulmonary embolism leading to right ventricular dysfunction. Thromb Res 134(5):1052–1056. https://doi.org/10.1016/j.thromres.2014.09.013. Epub 2014 Sep 21

  40. Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, Tirschwell DL (2017) Respect investigators. N Engl J Med 377(11):1022–1032

    Article  Google Scholar 

  41. Søndergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, Settergren M, Sjöstrand C, Roine RO, Hildick-Smith D, Spence JD, Thomassen L (2017) Gore REDUCE Clinical Study Investigators . Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 377(11):1033

    Article  Google Scholar 

  42. Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, Arquizan C, Béjot Y, Vuillier F, Detante O, Guidoux C, Canaple S, Vaduva C, Dequatre-Ponchelle N, Sibon I, Garnier P, Ferrier A, Timsit S, Robinet-Borgomano E, Sablot D, Lacour JC, Zuber M, Favrole P, Pinel JF, Apoil M, Reiner P, Lefebvre C, Guérin P, Piot C, Rossi R, Dubois-RandéJL EJC, Meneveau N, Lusson JR, Bertrand B, Schleich JM, Godart F, Thambo JB, Leborgne L, Michel P, Pierard L, Turc G, Barthelet M, Charles-Nelson A, Weimar C, Moulin T, Juliard JM, Chatellier G, CLOSE Investigators (2017) Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 377(11):1011

    Article  CAS  Google Scholar 

  43. Kottoor SJ, Arora RR (2018) Cryptogenic stroke: to close a patent foramen ovale or not to close? J Cent Nerv Syst Dis. 10:1179573518819476

  44. Powers WJ, Rabinstein AA (2018 Mar) 2018 Guidelines for the early management of patients with acute ischemic stroke. Stroke. 49(3):e46–e110. https://doi.org/10.1161/STR.0000000000000158 Epub 2018 Jan 24

  45. Sekhri V, Mehta N, Rawat N, Lehrman SG, Aronow WS (2012) Management of massive and nonmassive pulmonary embolism. Arch Med Sci 8(6):957–969. Published online 2012 Dec 19. https://doi.org/10.5114/aoms.2012.32402

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Sadaba JR, Greco E, Alvarez LA et al (2008) The surgical option in the management of acute pulmonary embolism. J Card Surg 23:729–732

    Article  Google Scholar 

  47. Takahashi H, Okada K, Matsumori M et al (2012) Aggressive surgical treatment of acute pulmonary embolism with circulatory collapse. Ann Thorac Surg 94:785–791. https://doi.org/10.1016/j.athoracsur.2012.03.101

    Article  PubMed  Google Scholar 

  48. Greelish JP, Leacche M, Solenkova NS et al (2011) Improved midterm outcomes for type A (central) pulmonary emboli treated surgically. J Thorac Cardiovasc Surg 142:1423–1429. https://doi.org/10.1016/j.jtcvs.2010.12.030

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Ka U. Lio

  2. Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcala, Madrid, Spain

    David Jiménez

  3. Department of Medicine, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, USA

    Lisa Moores

  4. Department of Thoracic Medicine and Surgery, Lewis Katz School Of Medicine, Temple University Hospital, Philadelphia, PA, USA

    Parth Rali

Authors
  1. Ka U. Lio
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David Jiménez
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lisa Moores
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Parth Rali
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Parth Rali.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Declarations

Not applicable.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

ESM 1

(DOCX 29 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lio, K.U., Jiménez, D., Moores, L. et al. Clinical conundrum: concomitant high-risk pulmonary embolism and acute ischemic stroke. Emerg Radiol 27, 433–439 (2020). https://doi.org/10.1007/s10140-020-01772-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10140-020-01772-7

Keywords

Search

Navigation