Simultaneous acute ischemic stroke (AIS) and acute pulmonary embolism (PE) is an uncommon but life-threatening clinical scenario that presents a significant therapeutic challenge. While AIS requires urgent cerebral reperfusion therapy, PE is primarily managed with anticoagulation or systemic thrombolysis. The coexistence of these conditions creates a difficult balance between preventing neurological deterioration and minimizing the risk of hemorrhagic transformation of cerebral infarction. We report the case of a 68-year-old woman presenting with acute neurological deficits in the setting of suspected pulmonary embolism and discuss the pathophysiology, diagnostic approach, current evidence, and decision-making process regarding thrombolytic therapy. We emphasize that management should be individualized according to stroke severity, PE severity, hemodynamic status, imaging findings, and bleeding risk.
Keywords: Acute ischemic stroke, Pulmonary embolism, Paradoxical embolism, Thrombolysis, Mechanical thrombectomy, Patent foramen ovale.
Acute ischemic stroke and pulmonary embolism are individually common medical emergencies. However, their simultaneous occurrence is rare, with only isolated case reports and small case series described in the literature. Their coexistence presents a unique therapeutic dilemma because the recommended treatments may conflict.
Acute ischemic stroke requires rapid reperfusion through intravenous thrombolysis or mechanical thrombectomy, whereas pulmonary embolism is primarily treated with immediate anticoagulation or systemic thrombolysis in high-risk cases. Early anticoagulation after cerebral infarction increases the risk of hemorrhagic transformation, while delaying anticoagulation may worsen pulmonary embolism. Therefore, treatment must be individualized based on the relative severity of both conditions.
A 68-year-old hypertensive woman presented to the emergency department with sudden-onset confusion and right-sided upper and lower limb weakness of one hour duration.
She reported intermittent episodes of breathlessness over the preceding month. One day before admission, evaluation at another hospital revealed oxygen desaturation to 92% on room air, but no definitive diagnosis was established.
On arrival, she was hemodynamically stable.
Neurological examination revealed confusion with right-sided hemiparesis. Her Glasgow Coma Scale score was E4VAM5. Pupils were equal and reactive.
Respiratory examination demonstrated bilateral equal air entry without adventitious sounds.
Cardiovascular examination showed normal heart sounds without murmurs and no elevation of jugular venous pressure.
Arterial Blood Gas
The echocardiographic findings suggested significant right ventricular pressure overload, raising strong suspicion for pulmonary embolism.
The most plausible mechanism is paradoxical embolism.
A venous thrombus originating in the lower limb travels to the pulmonary circulation, causing pulmonary embolism. Acute obstruction of the pulmonary vasculature increases right ventricular afterload and right atrial pressure. In patients with a patent foramen ovale (PFO), elevated right-sided pressures can reverse the interatrial pressure gradient, allowing thrombus to cross into the systemic circulation and embolize cerebral arteries, producing an acute ischemic stroke.
Deep vein thrombosis
↓
Pulmonary embolism
Raised right atrial pressure
Patent foramen ovale opens
Paradoxical embolism
Middle cerebral artery occlusion
Acute ischemic stroke
Other possible mechanisms include atrial fibrillation, left ventricular thrombus following myocardial infarction, infective endocarditis, or severe cardiomyopathy.
Diagnostic Evaluation
Patients with simultaneous neurological deficits and unexplained hypoxemia should undergo parallel evaluation for both stroke and pulmonary embolism.
The cornerstone of management is determining which condition poses the greater immediate threat to life or neurological outcome.
The decision to administer thrombolysis is not based solely on the diagnosis of stroke or PE. It depends on four major factors:
Patients with disabling stroke presenting within the thrombolysis window should generally receive reperfusion therapy if eligible.
These patients require immediate reperfusion because mortality is high without treatment.
Most patients are treated initially with anticoagulation.
Anticoagulation alone is appropriate.
Hemodynamic status is often the deciding factor.
Stable patients allow time for brain imaging and stroke-directed therapy, whereas unstable patients with massive PE may require immediate reperfusion despite recent cerebral infarction.
Factors increasing bleeding risk include:
This approach prioritizes neurological recovery.
Systemic thrombolysis should be prioritized because untreated massive PE carries an immediate risk of death.
Mechanical thrombectomy (if indicated) or intravenous thrombolysis should be performed first. Anticoagulation can be delayed while monitoring for hemorrhagic transformation. Temporary inferior vena cava filter placement may be considered if there is proven proximal DVT and anticoagulation is contraindicated.
Management should involve a multidisciplinary Pulmonary Embolism Response Team (PERT), stroke neurologist, cardiologist, and intensivist. Depending on available expertise, treatment options include systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, or surgical embolectomy.
Why Is Thrombolysis Based on Severity Rather Than Diagnosis?
The primary objective is to treat the condition with the highest immediate risk of death or irreversible disability.
Thus, thrombolysis is guided by clinical severity, hemodynamic status, imaging findings, and contraindications—not by the coexistence of stroke and pulmonary embolism alone.
Simultaneous acute ischemic stroke and pulmonary embolism is an uncommon but critical clinical emergency requiring rapid recognition and coordinated multidisciplinary care. The possibility of paradoxical embolism should be considered in patients presenting with acute neurological deficits in association with unexplained hypoxemia or right ventricular strain. Treatment should be individualized after careful assessment of stroke severity, pulmonary embolism severity, hemodynamic stability, infarct size, and bleeding risk. Rather than following a fixed protocol, clinicians should prioritize the condition posing the greatest immediate threat to life or neurological function. Early imaging, timely reperfusion when indicated, and appropriate sequencing of anticoagulation are essential to optimize outcomes.
This structure is appropriate for submission to an IMA journal as a case report with literature review, and it clearly emphasizes that the decision to thrombolyse depends on clinical severity, imaging, hemodynamic stability, and bleeding risk, rather than the presence of both diagnoses alone.
Dr. Ashok nandagopal, HOD , Department of Emergency Medicine Kauvery Hospital, Chennai.
Dr. Kowrilakshmi. U, Department of Emergency Medicine Kauvery Hospital, Chennai.
