Polytrauma patient with a massive pulmonary embolism and ischemic stroke in the setting of a patent foramen ovale

Case presentation

A patient in their 50s presented as a level-2 trauma activation after a motor vehicle collision. Their primary survey was intact. A FAST examination demonstrated a trace pericardial effusion without hemodynamic compromise and absent intraperitoneal fluid. Further radiographic investigations found left fourth through eighth and right seventh and eighth rib fractures, a right femur fracture, and right first through fourth metatarsal fractures. The patient was admitted to the Trauma Service, started on deep vein thrombosis (DVT) chemoprophylaxis (Lovenox 30 mg two times per day), and underwent a right femoral intramedullary nail placement and right metatarsal open reduction and internal fixation. The patient’s hospital course was complicated by (1) acute blood loss anemia (hemoglobin: 6.6 g/dL) secondary to a splenic laceration not present on index imaging requiring splenic and left gastric artery embolization (figure 1a,b), and (2) delayed bilateral upper extremity weakness secondary to chronic spinal stenosis and cervical subluxation found on MRI requiring a C_3-6 decompressive laminectomy. In the setting of a newly found left lower extremity DVT, an inferior vena cava (IVC) filter was placed due to institutional protocol to refrain from chemoprophylaxis immediately after neurosurgical interventions. Heparin 7500U TID was started on postoperative day 4. On the planned day of discharge, the patient underwent a left upper extremity ultrasound due to new onset edema in the setting of a previously placed peripherally inserted central catheter. An extensive DVT was found in the left innominate, axillary, and brachial veins. Later that day, secondary to acute onset hypoxia (SpO₂: 75%), tachycardia (HR: 135 BPM), and hypotension (SBP: 70 mm Hg), the patient was intubated and required three vasopressors to maintain a MAP of 65 mm Hg. A CT pulmonary embolus protocol angiogram showed evidence of acute bilateral pulmonary arterial emboli (figure 1c,d).

Figure 1. CT studies. (a) Admission abdominal CT study without splenic hemorrhage, (b) Repeat abdominal study demonstrating splenic hemorrhage, and (c, d) CT using pulmonary embolus protocol demonstrating filling defects suggestive of proximal right and left pulmonary artery emboli respectively.

What would you do?

1. Immediate open pulmonary embolectomy

2. Systemic thrombolysis

3. Consult Pulmonary Embolism Response Team (PERT)

4. Catheter directed thrombectomy and thrombolysis

5. Consult cardiology for an echocardiogram with bubble study

What we did and why

Correct answer: C

The PERT consultation guidance was to perform an open pulmonary embolectomy. A median sternotomy was performed, cardiopulmonary bypass was employed, and the pulmonary arteries (PAs) were visualized. Both PAs revealed large thrombi extending into the distal branches. All thrombi were removed. An intraoperative transesophageal echocardiogram (TEE) was performed; however, due to the patient’s hemodynamic instability, a bubble study was not done. A postoperative TEE with bubble study identified a patent foramen ovale (PFO). Additionally, ultrasound studies found left common, internal, and external partially occlusive carotid artery thrombi, and a CT angiogram demonstrated left anterior (ACA) and middle cerebral artery (MCA) occlusion with an associated ischemic stroke. Our Neuro-Interventional Radiology team was consulted. They performed a mechanical thrombectomy and successfully removed the left ACA occlusion. Ultimately, the patient’s course was complicated by sequela from the left ACA and MCA stroke leading to profound cerebral edema despite aggressive medical management. After several discussions between the surgical and ICU teams, the chaplain, and family, a decision was made to change the goals of care and the patient subsequently passed.

Pulmonary embolism management and treatment options have evolved over the past decade.¹ Modeled after rapid response teams, PERTs employ a multidisciplinary and collaborative approach to address high-risk patients with pulmonary embolism for whom treatment options are unclear.^{1 2} The PERT is comprised of clinicians—intensivists, surgeons, nurses, and supporting staff—who employ real-time consensus decision-making. Their goal is to provide a treatment course directed toward the patient’s hemodynamic profile and other factors while minimizing medical and surgical specialty specific biases such as anchoring to a providers’ knowledge basis and skill set. In our patient, the neurosurgical procedure’s contraindication for therapeutic chemoprophylaxis, the presence of an IVC filter, and the degree of pulmonary clot burden factored into our decision-making.

Confounding our patient’s PE was the PFO which likely resulted in the paradoxical left carotid artery emboli and subsequent stroke. This rare occurrence would have provided additional justification for an open pulmonary embolectomy due to the concurrent need for the cardiac defect’s closure. In the setting of a massive PE, right-to-left shunting may increase due to elevated right ventricular pressures, exacerbating hypoxia and increasing the stroke risk.

Previous studies found the ischemic stroke risk in patients presenting with a PE and concomitant PFO is ninefold higher than those without a PFO.³ Additionally, a PFO was only investigated in a minority of patients with PE, with one in four studies finding the defect.³ The association between PEs, PFOs, and potential adverse neurological consequences from embolic events mandates a preoperative or intraoperative bubble study in the hemodynamically stable patient as part of the routine care plan. Additionally, as evidenced by our patient, consultation with a PERT may provide comprehensive management solutions for these complex patients.