Abstract Introduction There are few reported cases of pulmonary embolism (PE) and acute stroke presenting together. As such, there are no specific guidelines regarding management in these cases. Here, we present a case of a patient with concomitant PE and stroke who underwent thrombectomy for her stroke under conscious sedation, followed by prompt escalation of anticoagulation without hemorrhagic conversion of her stroke. Case Summary A 73-year-old female with no significant medical history presented with acute dysphagia, right-sided weakness, and a few weeks of dyspnea. She was hypoxic, requiring heated high-flow nasal cannula, but was otherwise hemodynamically stable. Computed tomographic angiography (CTA) of the chest showed saddle PE with bilateral lobar, segmental, and subsegmental emboli. She had elevated troponin and evidence of right heart strain on imaging, consistent with intermediate-high-risk PE. CTA of the head demonstrated a large vessel occlusion of the left middle cerebral artery. After a multidisciplinary discussion with neurology, pulmonology, anesthesia, and interventional radiology, the decision was made to pursue stroke thrombectomy under conscious sedation due to concerns regarding the use of general anesthesia in the setting of right heart strain. The patient had markedly improved neurologic status after recanalization. Heparin infusion was initiated, and within one day she reached therapeutic range with no hemorrhagic conversion on repeat imaging. Discussion Induction of general anesthesia, which is often used in stroke thrombectomy, carries significant hemodynamic risk in patients with right heart strain. Positive-pressure ventilation and general anesthesia can precipitate cardiovascular collapse by increasing pulmonary vascular resistance, reducing coronary perfusion, and decreasing venous return to an already preload-dependent right ventricle. Conscious sedation, used less frequently in neurointerventional procedures, may offer a hemodynamically safer alternative by preserving spontaneous ventilation and sympathetic tone. Another challenging aspect of this case was the timing of anticoagulation. Prompt therapeutic anticoagulation is critical in PE management, especially with right heart strain. Incomplete anticoagulation also precludes the use of life-saving, catheter-based therapies such as mechanical thrombectomy. Early therapeutic anticoagulation after stroke, however, increases the risk of hemorrhagic transformation. Neurology practice favors gradual escalation to therapeutic range, with delays of up to 14 days recommended for larger cerebral infarcts. If infarct burden appears small and there is no hemorrhagic conversion on post-thrombectomy imaging, it may be reasonable to advance anticoagulation earlier to mitigate PE-related mortality. Our case underscores the need for individualized procedural planning and interdisciplinary collaboration to address the multisystem considerations in patients with concurrent cerebrovascular and pulmonary thromboembolism. This abstract is funded by: None
Blackman et al. (Fri,) studied this question.