Massive brainstem infarction and high-risk pulmonary embolism successfully treated with pharmaco-invasive approach: A...

Concurrent acute massive brainstem infarction and high-risk pulmonary embolism (PE) present a critical therapeutic dilemma due to contraindications for thrombolysis in acute stroke. Such cases are rarely reported, and optimal management strategies remain undefined. This case highlights the challenges and underscores the importance of timely mechanical intervention in life-threatening dual pathologies.

A 63-year-old man was admitted to the hospital with partial paralysis of his left leg, which had been unresponsive for 7 hours. In the emergency department, magnetic resonance imaging of the head showed multiple recent infarctions of the brainstem and right cerebellar hemisphere. The patient was therefore diagnosed with an acute cerebral infarction. After nearly a week of treatment, including anticoagulation and plaque stabilization, his condition improved significantly. On his seventh day of hospitalization, after waking up and going to the bathroom, his oxygenation suddenly decreased, accompanied by hypotension and shock.

After a comprehensive analysis, we considered the possibility of a PE. Subsequent computed tomographic pulmonary angiography confirmed this to be the case, pointing to a massive high-risk lesion.

Anticoagulation with unfractionated heparin failed to stabilize hemodynamics. Multidisciplinary consensus prioritized pulmonary artery thrombectomy with catheter-directed thrombolysis, avoiding systemic thrombolysis risks.

Post-thrombectomy, hemodynamic stability was restored. Anticoagulation was successfully transitioned from unfractionated heparin to rivaroxaban, achieving complete thrombus resolution at 3 months. The patient regained functional capacity without hemorrhagic complications.

This case demonstrates that pulmonary artery thrombectomy is a viable lifesaving option for high-risk PE when thrombolysis is contraindicated in acute stroke. It emphasizes the role of multidisciplinary decision-making and mechanical interventions in dual critical pathologies, offering a framework for managing similar complex cases.