Acute pulmonary embolism (PE) is a common and sometimes fatal consequence of venous thromboembolism. Within the United Kingdom, the incidence of diagnosed PE is 3-4/10,000 though it is likely to be underestimated1. Internationally, the incidence is 4-21/10,0002. It is associated with a 30 day mortality of 4% and a 1 year mortality of 13%3. Within the UK, it is thought to account for 60,000 deaths annually4.
Management options include thrombolysis, thrombectomy, and anticoagulation with supportive management. Main indications for thrombolysis is haemodynamic instability manifesting as:
Currently catheter directed thrombolysis is still only to be considered in PE with haemodynamic instability, although reduction in mortality remains unclear following both NICE and Cochrane reviews5,6. There is no set recommendations for surgical embolectomy due to limited evidence in the literature.
52 year old gentleman with a past medical history of diabetes mellitus type 2, hypertension, oesophagitis, and paranoid personality disorder.
Diagnosed with PE on CTPA, started on rivaroxaban
Readmitted 8 weeks later due to noncompliance with medication, haemoptysis, and a frontal headache under the acute medical team without any focal neurology.
CT Head revealed no abnormalities, but CTPA demonstrated extension of the PE and evidence of right heart strain.
Within 24 hours, the patient desaturated to 60% and was intubated and ventilated after a cardiac arrest call was issued. Admitted to ITU and thrombolysed.
Initial ECHO – Biventricular failure with EF 10-15%, however LIDCO demonstrated improving cardiac function and respiratory support decreased during 2-3 days post thrombolysis suggesting improvement in clot burden.
Day 3 post thrombolysis, patient found to not wake following sedation hold and noted not to be moving right arm. Urgent CT Head revealed substantial thrombus in the Left MCA and extensive infarction in the left hemisphere with some mass effect in addition to a right occipito-parietal infarct.
Best interest meeting with IMCA concluded in palliation.
Evidence should guide practice as to management of pulmonary embolus. However, there may be specific patient factors which increase an individuals risk for interventions and decisions should be made on a case by case basis.
The risk of haemorrhageand haemorrhagicstroke is a well known complication following thrombolysis. However, thromboembolic events are rarely reported and there are currently no publications reporting ischaemicstroke secondary to embolic fracture from a pulmonary embolus. The risk of haemorrhagemay be attenuated with catheter directed thrombolysis when compared to systematic thrombolysis but this is associated with the additional risk of pulmonary artery rupture. NICE is currently encouraging research into Ultrasound enhanced catheter directed thrombolysis. Surgical thrombectomy is currently reserved for patients in whom thrombolysis is contraindicated or where thrombolysis has failed. Ischaemicstrokes may demonstrate no change in an initial CT scan and thus can be falsely reassuring if one were only contemplating haemorrhagicstrokes. A high index of suspicion is required when managing these patients, particularly whilst the evidence base is evolving.