Diagnosis and Management of Ischemic Stroke Secondary to Pulmonary Embolism in Elderly Patients
Hamsa Baravi *
Seha Emirates Hospital, Abu Dhabi, United Arab Emirates.
*Author to whom correspondence should be addressed.
Abstract
Timely diagnosis and management of pulmonary embolism-induced ischemic stroke in elderly patients pose significant challenges. Definitive diagnosis relies on comprehensive imaging studies like non-contrast brain MRI and computed tomography pulmonary angiography to identify and locate affected vascular territories. Transthoracic echocardiogram with agitated saline contrast proves valuable in understanding potential causes of acute ischemic stroke, aiding in detecting Patent Foramen Ovale (PFO)or intra-atrial thrombi, and providing insights into PE severity through right heart strain identification. TTE's prognostic value helps predict the condition's outcome, while Transesophageal echocardiogram accompanies TTE when results are inconclusive. Lower extremity ultrasound is crucial for comprehensive deep vein thrombosis evaluation in elderly patients, and considering occult malignancy workup (pan scan) and pelvic MR Venogram for May-Thurner syndrome is important. However, limited information on testing frequency for occult malignancy and MTS may contribute to the presence of both PFO and DVTs in multiple patients. Treatment approaches for PE-induced ischemic stroke vary based on severity and individual considerations. Acute thrombolysis with intravenous recombinant tissue plasminogen activator and mechanical thrombectomy effectively manageAIS. Intravenous heparin is a common choice for systemic anticoagulation in PE, necessitating prompt initiation to avoid worsening outcomes. However, anticoagulation alone for AIS does not improve prognosis or prevent future occurrences. Prompt IV rt-PA consideration in severe AIS cases with a high risk of hemorrhagic conversion is crucial. While having a stroke in the past six months is an absolute contraindication for PE thrombolytic therapy, it may be considered relative in life-threatening PE scenarios. In conclusion, S. OKtimelydiagnosis and appropriate management of PE-induced ischemic stroke in elderly patients necessitate a multidisciplinary approach. Integrating imaging studies, echocardiograms, and comprehensive thrombosis and malignancy evaluations is vital.
Keywords: Pulmonary embolism, ischemic stroke, Elderly patient
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Feigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W, et al. World Stroke Organization (WSO): global stroke fact sheet 2022. International Journal of Stroke. 2022;17(1):18-29.
Feske SK. Ischemic stroke. The American Journal of Medicine. 2021;134(12): 1457-64.
Freund Y, Cohen-Aubart F, Bloom B. Acute pulmonary embolism: A review. Jama. 2022;328(13):1336-45.
Culp MB, Soerjomataram I, Efstathiou JA, Bray F, Jemal A. Recent global patterns in prostate cancer incidence and mortality rates. European Urology. 2020;77(1): 38-52.
Wang W, Wang D, Liu H, Sun H, Jiang B, Ru X, et al. The trend of declining stroke mortality in China: reasons and analysis. Stroke and Vascular Neurology. 2017; 2(3).
Jabagi MJ, Bertrand M, Botton J, Le Vu S, Weill A, Dray-Spira R, et al. Stroke, myocardial infarction, and pulmonary embolism after bivalent booster. New England Journal of Medicine. 2023; 388(15):1431-2.
Le Moigne E, Timsit S, Ben Salem D, Didier R, Jobic Y, Paleiron N, et al. Patent foramen ovale and ischemic stroke in patients with pulmonary embolism: a prospective cohort study. Annals of Internal Medicine. 2019;170(11): 756-63.
Chakir M, El Jamili M, Boudhar Z, El Hattaoui M. Simultaneous acute myocardial infarction, bilateral pulmonary embolism, and acute ischaemic cerebral stroke, a delayed complication in a patient with COVID-19 infection: a case report. European Heart Journal-Case Reports. 2021;5(6):ytab218.
Varma Y, Shah R, Shah Y, Patel BA, Halabi AR, Aloka F, et al. Triple trouble: large right cerebral stroke with hemorrhagic transformation, dvt and massive pulmonary embolism. Journal of the American College of Cardiology. 2023;81(8_Supplement): 3128.
Zietz A, Sutter R, De Marchis GM. Deep vein thrombosis and pulmonary embolism among patients with a cryptogenic stroke linked to patent foramen ovale—A review of the literature. Frontiers in Neurology. 2020;11:336.
Fernandes TM, Alotaibi M, Strozza DM, Stringer WW, Porszasz J, Faulkner GG, et al. Dyspnea post pulmonary embolism from physiological dead space proportion and stroke volume defects during exercise. Chest. 2020;157(4): 936-44.
Wang X, Liang H, Deng X, Cen G, Chen S, Chen X, et al. Cervical cancer patient with deep venous thrombosis developing fatal ischemic stroke within 24 hours after surgery: a case report; 2023.
Rezny BR, Tyagi A, Crumley JP, Rappaport KA, Arora L. Saddle Up: anticoagulation for extracorporeal membrane oxygenation in a pulmonary embolism and ischemic stroke—A case report. A&A practice. 2020;14(10):e01277.
Liu J, Yuan J, Zhao J, Zhang L, Wang Q, Wang G. Serum metabolomic patterns in young patients with ischemic stroke: a case study. Metabolomics. 2021;17:1-10.
Parać E, Herceg S, Boban M, Negovetić P, Tolić NB. CR65 Pulmonary embolism as a cause of cardiac arrest in a patient after a stroke. Lijecnicki Vjesnik. 2023; 145.
Sluis WM, Linschoten M, Buijs JE, Biesbroek JM, den Hertog HM, Ribbers T, et al. Risk, clinical course, and outcome of ischemic stroke in patients hospitalized with COVID-19: a multicenter cohort study. Stroke. 2021;52(12):3978-86.
Casatori L, Pellegrino A, Messineo A, Ghionzoli M, Facchini F, Modesti A, et al. Differential influence of physical activity on cardiopulmonary performance and stroke volume assessed at cardiopulmonary exercise test in pectus excavatum: a pilot study. Frontiers in Physiology. 2022; 13:831504.PAGINAS 1-7
Mojadidi MK, Bogush N, Caceres JD, Msaouel P, Tobis JM. Diagnostic accuracy of transesophageal echocardiogram for the detection of patent foramen ovale: a meta‐analysis. Echocardiography. 2014; 31(6):752-8.
Pongmoragot J, Rabinstein AA, Nilanont Y, Swartz RH, Zhou L, Saposnik G. Pulmonary embolism in ischemic stroke: clinical presentation, risk factors, and outcome. J Am Heart Assoc. 2013;2(6):e000372.
Barros-Gomes S, Sabbagh AE, Eleid MF, Mankad SV. Concomitant acute stroke, pulmonary and myocardial infarction due to in-transient thrombus across a patent foramen ovale. Echo Research & Practice. 2018;5(4):I9-I10.
Benramdane H, Nasri S, Ouahabi N, Belharti A, Chehita K, Yassine M, et al. Multiple ischemic strokes with pulmonary embolism revealing severe COVID-19 infection in a young healthy patient. Radiology Case Reports. 2022;17(12): 4879-84.
Press RD, Liu X-Y, Beamer N, Coull BM. Ischemic Stroke in the Elderly. Stroke. 1996;27(1):44-8.
Omar H, Huang C, Miller J, Mangar D, Kabemba A, Camporesi E. Simultaneous pulmonary embolism and cerebrovascular stroke. Herz. 2013;38(8):884.
Christiansen ME, Kumar G, Mahabir RC, Helmers RA, Bendok BR, O’Carroll CB. Intravenous alteplase for acute stroke and pulmonary embolism in a patient with recent abdominoplasty. The Neurologist. 2017;22(4):150-2.
Grosu O, Băitoi S. Pulmonary embolism in stroke patients: autopsy results study. European Stroke Journal. 2021;16(Supl. 2):128.
Velez FGS, Garcia JGO. Management dilemmas in acute ischemic stroke and concomitant acute pulmonary embolism: case series and literature review. Eneurologicalsci. 2021;23: 100341.
Seiffge DJ, Werring DJ, Paciaroni M, Dawson J, Warach S, Milling TJ, et al. Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. The Lancet Neurology. 2019; 18(1):117-26.
Michota F. Transitions of care in anticoagulated patients. Journal of Multidisciplinary Healthcare. 2013:215-28.
Maturana MA, Seitz MP, Pour-Ghaz I, Ibebuogu UN, Khouzam RN. Invasive strategies for the treatment of pulmonary embolism. Where are we in 2020? Current Problems in Cardiology. 2021;46(3): 100650.
Douketis JD. The 2016 American College of Chest Physicians treatment guidelines for venous thromboembolism: a review and critical appraisal. Internal and emergency medicine. 2016;11:1031-5.
Robba C, Bonatti G, Battaglini D, Rocco PR, Pelosi P. Mechanical ventilation in patients with acute ischaemic stroke: from pathophysiology to clinical practice. Critical Care. 2019;23:1-14.