- A 45 yo male with PMH of morbid obesity, hypertension, congestive heart failure, diabetes mellitus type II, and obstructive sleep apnea presented for evaluation of shortness of breath and hemoptysis x24hrs.
- The patient had completed a 22hr non-stop car trip the day prior to presentation.
- CTA Chest revealed multiple acute pulmonary emboli involving the right middle and lower lobe segmental and subsegmental pulmonary arteries, straightening of the interventricular septum likely related to right heart strain, right lower lobe consolidations which likely represent pulmonary infarcts with hemorrhage and large filling defect withing the right atrium which likely represents thrombus.
- Subsequent TTE with poor images but did raise the possibility of an intracardiac thrombus. The right ventricle was dilated with reduced systolic function. Pa pressure was estimated to be moderately elevated at 62mmHg.
- Patient’s vital signs at presentation: BP 126/80 HR 92 RR26 T 36.9 O2 sat 84% on RA and 91% on 5LO2
- BNP 524 and troponins 0.06, 0.08, and 0.07
- He was initiated on a heparin gtt.
- On hospital day 6 he began vomiting, developed acute mental status changes and required intubation for worsened hypoxia.
- Head CT non-contrast done at that time was normal. Head CTA was not completed due to clinical instability.
- TTE with a bubble study done the following day revealed a PFO with large right to left shunt.
- On hospital day 12 a repeat Head CT was done for continued obtundation despite withdrawal of all sedation which revealed cerebral edema and transtentorial herniation. Brain angiogram revealed no flow beyond the basilar trunk.
- On hospital day 21 life support was withdrawn and the patient expired.
- Autopsy revealed basilar artery with complete occlusion with organized thromboemboli. Cardiac postmortem examination demonstrated large right atrial thrombus and PFO.
- Normotensive patients with acute PE, evidence of RV dysfunction, elevated troponin and BNP are classified as having intermediate risk PE and constitute a large population at risk for adverse events.
- PFO is common in the general population and is an important prognostic indicator for high risk of paradoxical systemic arterial embolization and death.
- The MOPPETT trial demonstrated ½ dose TPA to be safe and effective in the treatment of moderate PE as well as resulting in a significant early reduction in pulmonary artery systolic pressure.
- Early reduction of the pulmonary artery systolic pressure for our patient may have allowed the PFO to close and reduced his risk of system arterial emboliztion.
- The PEITHO study demonstrated an increased risk of major hemorrhage without clear clinical benefit for patients with intermediate PE receiving thrombolytics causing many physicians to shy away from thrombolytics for patients with intermediate risk PE.
- However further meta-analysis has shown that TPA did not confer a significantly increased risk for major bleeding in patients 65 years of age or younger.
- Patients with intermediate risk PE and PFO represent a sub-category of intermediate risk PE patients at increased risk for adverse events.
- Screening echo for PFO should be performed for patients with intermediate risk PE.
- Due to the significant mortality and stroke risks for patients with submassive PE and PFO thrombolysis with ½ dose tPA should be considered in younger patients (asuming no significant contraindications to thrombolysis) in order to restore normal right sided hemodynamics and decrease the risk of paradoxical system arterial embolization.
To cite this abstract:Eisenstock K. Basilar Artery Stroke in the Setting of Submassive Pulmonary Embolus and Patent Foramen Ovale. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 513. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/basilar-artery-stroke-in-the-setting-of-submassive-pulmonary-embolus-and-patent-foramen-ovale/. Accessed September 19, 2019.