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Lio KU, Jiménez D, Moores L, Rali P. Clinical conundrum: concomitant high-risk pulmonary embolism and acute ischemic stroke. Emerg Radiol 2020; 27:433-439. [PMID: 32211984 DOI: 10.1007/s10140-020-01772-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 01/01/2023]
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.
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Affiliation(s)
- Ka U Lio
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcala, Madrid, Spain
| | - Lisa Moores
- Department of Medicine, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School Of Medicine, Temple University Hospital, Philadelphia, PA, USA.
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Klang E, Kerpel A, Soffer S, Zlotnik M, Shimon O, Rimon U, Konen E, Amitai MM. CT imaging features of symptomatic and asymptomatic floating aortic thrombus. Clin Radiol 2017; 73:323.e9-323.e14. [PMID: 29150083 DOI: 10.1016/j.crad.2017.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
Abstract
AIM To present the computed tomography (CT) imaging features of floating aortic thrombus with emphasis on clinical and radiographic predictors for systemic shower emboli. MATERIALS AND METHODS A retrospective computerised search for patients with protruding thoracic aortic thrombus on CT was conducted. Clinical and demographic characteristics were retrieved from medical files. Patients were divided into two groups: symptomatic and asymptomatic, based on the presence or absence of documented systemic emboli at the time of diagnosis or during follow-up. CT imaging features were analysed: location and extent of systemic emboli, presence or absence of thrombus insertion calcification, percentage of thrombus circumference that is attached to the aortic wall and thrombus volume. Clinical and demographic variables and CT imaging features were analysed as potentially associated with symptomatic emboli. RESULTS The symptomatic group included 6/15 (40%) patients and the asymptomatic group included 9/15 (60%) patients. Patients in the symptomatic group were significantly younger (symptomatic: 53.3±11.7 years, asymptomatic: 76.9±8.4 years, p=0.003). All the symptomatic patients were women (100%), while 2/9 (22.2%) of the asymptomatic patients were women, (p=0.007). A non-calcified insertion site was more frequent in the symptomatic group (symptomatic 4/6 [66.7%] versus asymptomatic group 1/9 [11.1%], p=0.011). The percentage of thrombus circumference attached to the aortic wall was significantly smaller in symptomatic patients (symptomatic: 31.8±8.4%, asymptomatic: 43.7±5%, p=0.003). CONCLUSION The imaging features of symptomatic floating thrombus include a narrow base of attachment and lack of insertion calcification. Free-floating thrombus should be actively sought and diagnosed or excluded when performing CT andiography for emboli.
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Affiliation(s)
- E Klang
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Emek HaEla St 1, Ramat Gan, 5265601, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Chaim Levanon St 30, Tel-Aviv, 6997801, Israel
| | - A Kerpel
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Emek HaEla St 1, Ramat Gan, 5265601, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Chaim Levanon St 30, Tel-Aviv, 6997801, Israel
| | - S Soffer
- Tel-Aviv University, Sackler Faculty of Medicine, Chaim Levanon St 30, Tel-Aviv, 6997801, Israel.
| | - M Zlotnik
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Emek HaEla St 1, Ramat Gan, 5265601, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Chaim Levanon St 30, Tel-Aviv, 6997801, Israel
| | - O Shimon
- Tel-Aviv University, Sackler Faculty of Medicine, Chaim Levanon St 30, Tel-Aviv, 6997801, Israel
| | - U Rimon
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Emek HaEla St 1, Ramat Gan, 5265601, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Chaim Levanon St 30, Tel-Aviv, 6997801, Israel
| | - E Konen
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Emek HaEla St 1, Ramat Gan, 5265601, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Chaim Levanon St 30, Tel-Aviv, 6997801, Israel
| | - M M Amitai
- Department of Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Emek HaEla St 1, Ramat Gan, 5265601, Israel; Tel-Aviv University, Sackler Faculty of Medicine, Chaim Levanon St 30, Tel-Aviv, 6997801, Israel
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Zhang HL, Liu ZH, Luo Q, Wang Y, Zhao ZH, Xiong CM. Paradoxical embolism: Experiences from a single center. Chronic Dis Transl Med 2017; 3:123-128. [PMID: 29063065 PMCID: PMC5627697 DOI: 10.1016/j.cdtm.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To present our treatment experiences and the follow-up data of patients with paradoxical embolism (PDE). METHODS The clinical characteristics, management, and follow-up data of all included patients who were diagnosed with PDE at Fuwai Hospital from January 1994 to October 2015 were recorded. RESULTS Twelve patients were included; all had a pulmonary embolism, and 8 had deep venous thrombosis. The artery embolisms involved the cerebral artery (7 patients), renal artery (2 patients), mesentery artery (2 patients), popliteal artery (1 patient), descending aorta thrombus (1 patient), and thrombus-straddled patent foramen ovale (PFO) (1 patient). PFO was found in 3 cases. One patient underwent thrombectomy and PFO closure; Six patients received thrombolysis; and 3 patients were implanted with a vena cava filter. Long-term anticoagulation with warfarin was recommended for each patient. One patient died from ventricular fibrillation despite cardiopulmonary resuscitation. Eleven patients were discharged with improvements. No late mortality occurred in 8 patients with a complete follow-up of 10.6-17.7 years. One had a recurrent deep venous thrombosis. No patient had a recurrent pulmonary or arterial embolism. Two patients changed their treatment from warfarin to aspirin; others remained on warfarin. Only 1 case had an occasional gum bleeding. CONCLUSIONS PDE treatment including thrombolysis, anticoagulation, and embolectomy should be individualized. We recommend long-term anticoagulation therapy to prevent the recurrence of PDE, especially to those with an intracardiac communication or persistent risk factors for re-thrombosis.
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Affiliation(s)
- Hong-Liang Zhang
- Center for Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hong Liu
- Center for Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qin Luo
- Center for Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yong Wang
- Center for Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hui Zhao
- Center for Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chang-Ming Xiong
- Center for Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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