Successful Thrombolysis of a Stroke with a Pulmonary Embolism in a Young Woman

Abstract

Paradoxical embolism is a rare event, accounting for < 2% of all arterial emboli. The diagnosis is often difficult, and consequences for the patient can be severe. We describe the case of a 35-year-old female physician who presented to our Emergency Department (ED) in severe hemodynamic compromise, with an altered level of consciousness and major expressive aphasia 1 day after undergoing a leg varicosal stripping procedure under regional anesthesia. She was successfully thrombolyzed with 0.9 mg/kg of Recombinant Tissue Plasminogen Activator (rtPA, Alteplase) and had a full recovery. To our knowledge, this is the first description of a case of massive pulmonary embolism associated with a paradoxical stroke related to patent foramen ovale that was thrombolyzed for both conditions with a "neurological dose" of rtPA. Although thrombolysis was completely successful in this case, indications and contraindications should be thoroughly respected. A more conservative approach with anticoagulation, or a more aggressive approach with surgical thrombectomy, can each potentially have a place in particular cases. Intra-arterial catheter-directed thrombolysis and percutaneous embolectomy are additional options to be considered when available, especially if there are contraindications for systemic thrombolysis.