Multimodality Imaging Evaluation of Reverse McConnell’s Sign and Right Ventricular Apical Thrombosis in Acute Pulmonary Embolism

McConnell’s sign, characterized by hypokinesia of the mid-free wall of the right ventricle (RV) with preserved apical contractility, is a well-recognized echocardiographic marker in acute pulmonary embolism (PE). However, its reverse variant—apical akinesia with preserved basal function—is rare and less understood. We report the case of an 85-year-old woman presenting with acute PE, who exhibited a rare form of RV dysfunction known as Reverse McConnell’s sign. Multimodality imaging—including computed tomography (CT), transthoracic echocardiography, and cardiac magnetic resonance (CMR)—revealed apical RV akinesia and a concurrent intracavitary thrombus at the RV apex. Based on imaging, laboratory biomarkers, and clinical findings, an intermediate-high risk PE was diagnosed. The patient was managed with anticoagulation, and follow-up imaging demonstrated complete recovery of RV function and resolution of the thrombus. This case highlights the diagnostic and risk-stratification utility of a multimodality imaging approach in evaluating patients with acute PE. Uncommon RV contraction patterns might be present in PE, and potential complications such as intraventricular thrombosis should be assessed and followed-up. In conclusion, reverse McConnell’s sign, though uncommon, should be recognized as a potential manifestation of acute PE. Multimodal imaging plays a crucial role in its identification, differential diagnosis, and follow-up.