J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website https://jocmr.elmerjournals.com

Review

Volume 17, Number 1, January 2025, pages 1-13

Strategies in Management of Pulmonary Embolism With Acute Ischemic Stroke: A Systematic Review

Table 1. Risk of Bias

Questions

Dada et al, 2018 [28]

Barros-Gomes et al, 2018 [24]

Delgado et al, 2012 [10]

Hattori et al, 2019 [29]

Christiansen et al, 2017 [17]

De Oliveira et al, 2016 [27]

Gunta and Kamath, 2012 [11]

Konala et al, 2019 [18]

Lio et al, 2019 [13]

Bagate et al, 2018 [12]

Pan et al, 2019 [20]

Pelletier et al, 2010 [9]

Saleh Velez and Ortiz Garcia, 2021 [19]

Duy et al, 2019 [25]

Ozsancak Ugurlu et al, 2015 [23]

Xie et al, 2014 [16]

Chakir et al, 2021 [21]

Naidoo and Hift, 2011 [15]

Nam et al, 2015 [26]

Omar et al, 2013 [22]

Jayalakshmi et al, 2021 [14]

Selection
1. Does the patient(s) represent(s) the whole experience of the investigator (center) or is the selection method unclear to the extent that other patients with similar presentation may not have been reported?

Yes

Ascertainment
2. Was the exposure adequately ascertained?

Yes

Ascertainment
3. Was the outcome adequately ascertained?

Yes

Causality
4. Were other alternative causes that may explain the observation ruled out?

Yes

Causality
5. Was there a challenge/rechallenge phenomenon?

N/A

Causality
6. Was there a dose response effect?

N/A

Causality
7. Was follow-up long enough for outcomes to occur?

Yes

Reporting
8. Is the case(s) described with sufficient details to allow other investigators to replicate the research or to allow practitioners make inferences related to their own practice?

Yes

**Table 2.** GRADE Analysis for Included Studies
Study	Year	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Publication bias	Quality of evidence	GRADE
Dada et al [28]	2018	Case report	High	None	Direct	None	Not significant	Low	Low
Barros-Gomes et al [24]	2018	Case report	High	None	Direct	None	Not significant	Low	Low
Delgado et al [10]	2012	Case report	High	None	Direct	None	Not significant	Low	Low
Hattori et al [29]	2019	Case report	High	None	Direct	None	Not significant	Low	Low
Christiansen et al [17]	2017	Case report	High	None	Direct	None	Not significant	Low	Low
De Oliveira et al [27]	2016	Case report	High	None	Direct	None	Not significant	Low	Low
Gunta and Kamath [11]	2012	Case report	High	None	Direct	None	Not significant	Low	Low
Konala et al [18]	2019	Case report	High	None	Direct	None	Not significant	Low	Low
Lio et al [13]	2019	Case report	High	None	Direct	None	Not significant	Low	Low
Bagate et al [12]	2018	Case report	High	None	Direct	None	Not significant	Low	Low
Pan et al [20]	2019	Case report	High	None	Direct	None	Not significant	Low	Low
Pelletier et al [9]	2010	Case report	High	None	Direct	None	Not significant	Low	Low
Saleh Velez and Ortiz Garcia [19]	2021	Case report	High	None	Direct	None	Not significant	Low	Low
Duy et al [25]	2019	Case report	High	None	Direct	None	Not significant	Low	Low
Ozsancak Ugurlu et al [23]	2015	Case report	High	None	Direct	None	Not significant	Low	Low
Xie et al [16]	2014	Case report	High	None	Direct	None	Not significant	Low	Low
Chakir et al [21]	2021	Case report	High	None	Direct	None	Not significant	Low	Low
Naidoo et al [15]	2011	Case report	High	None	Direct	None	Not significant	Low	Low
Nam et al [26]	2015	Case report	High	None	Direct	None	Not significant	Low	Low
Omar et al [22]	2013	Case report	High	None	Direct	None	Not significant	Low	Low
Jayalakshmi et al [14]	2021	Case report	High	None	Direct	None	Not significant	Low	Low

Table 2. GRADE Analysis for Included Studies

Study

Year

Study design

Risk of bias

Inconsistency

Indirectness

Imprecision

Publication bias

Quality of evidence

GRADE

Dada et al [28]

2018

Case report

High

None

Direct

None

Not significant

Low

Barros-Gomes et al [24]

2018

Case report

High

None

Direct

None

Not significant

Low

Delgado et al [10]

2012

Case report

High

None

Direct

None

Not significant

Low

Hattori et al [29]

2019

Case report

High

None

Direct

None

Not significant

Low

Christiansen et al [17]

2017

Case report

High

None

Direct

None

Not significant

Low

De Oliveira et al [27]

2016

Case report

High

None

Direct

None

Not significant

Low

Gunta and Kamath [11]

2012

Case report

High

None

Direct

None

Not significant

Low

Konala et al [18]

2019

Case report

High

None

Direct

None

Not significant

Low

Lio et al [13]

2019

Case report

High

None

Direct

None

Not significant

Low

Bagate et al [12]

2018

Case report

High

None

Direct

None

Not significant

Low

Pan et al [20]

2019

Case report

High

None

Direct

None

Not significant

Low

Pelletier et al [9]

2010

Case report

High

None

Direct

None

Not significant

Low

Saleh Velez and Ortiz Garcia [19]

2021

Case report

High

None

Direct

None

Not significant

Low

Duy et al [25]

2019

Case report

High

None

Direct

None

Not significant

Low

Ozsancak Ugurlu et al [23]

2015

Case report

High

None

Direct

None

Not significant

Low

Xie et al [16]

2014

Case report

High

None

Direct

None

Not significant

Low

Chakir et al [21]

2021

Case report

High

None

Direct

None

Not significant

Low

Naidoo et al [15]

2011

Case report

High

None

Direct

None

Not significant

Low

Nam et al [26]

2015

Case report

High

None

Direct

None

Not significant

Low

Omar et al [22]

2013

Case report

High

None

Direct

None

Not significant

Low

Jayalakshmi et al [14]

2021

Case report

High

None

Direct

None

Not significant

Low

**Table 3.** Patient Information, Risk Factors and Presenting Symptoms
Study	Age/sex	Risk factors	Presenting symptoms
COPD: chronic obstructive pulmonary disease; DVT: deep vein thrombosis; GI: gastrointestinal; HIV: human immunodeficiency virus; OCP: oral contraceptive pill; PE: pulmonary embolism; SLE: systemic lupus erythematosus.
Pelletier et al, 2010 [9]	35/F	Recent leg varicosal stripping, one spontaneous abortion, OCP use	Collapsed, altered consciousness, expressive aphasia, subtle facial asymmetry
Delgado et al, 2012 [10]	76/F	Hypertension, dyslipidemia	Sudden right leg paresis and hypoesthesia
Gunta and Kamath, 2012 [11]	16/F	Long car ride, OCP, family history of venous thromboses and PE, MTHFR mutation, antithrombin III deficiency	Unresponsive, labored respirations, shortness of breath, cough, leg pain for 2 days
Bagate et al, 2018 [12]	44/M	Psychiatric disorder	Non-shockable cardiac arrest, impaired consciousness
Lio et al, 2019 [13]	69/M	Testicular carcinoma	Signs of cardiogenic shock, questionable GI bleeding
Jayalakshmi et al, 2021 [14]	52/M	Not mentioned	Not mentioned
Naidoo and Hift, 2011 [15]	38/F	Immobility, dilated cardiomyopathy, HIV on antiretroviral therapy	Dyspnea, pleuritic chest pain, right-sided hemiplegia
Xie et al, 2014 [16]	55/F	History of varicose veins of lower extremities	Chest distress, dyspnea, loss of consciousness, sudden non-fluent language, dyskinesis of right extremities
Christiansen et al, 2017 [17]	59/F	Post-operative day 2 abdominoplasty and liposuction, OCP	Left-sided weakness, dysarthria, acute respiratory distress
Konala et al, 2019 [18]	82/M	Type 2 diabetes mellitus, previous lower extremity DVT	Loss of consciousness while urinating, mild dyspnea before syncope
Saleh Velez and Ortiz Garcia, 2021 [19]	72/F	Not mentioned	Collapsed, comatose state, flaccid quadriplegia, cardiac arrest
Saleh Velez and Ortiz Garcia, 2021 [19]	75/F	Hypertension	Mild dysarthria, right arm paresis, severe pleuritic pain, shortness of breath
Pan et al, 2019 [20]	27/F	Post-operative day 7 C-section, Glenn anastomosis 7 years prior for cor biloculare	Dizziness, chest tightness, dysarthria, facial asymmetry, right hemiparesis
Chakir et al, 2021 [21]	60/M	Type II diabetes, COVID-19 infection	Left hemiplegia, typical anginal chest pain, hypotonia, left sensory deficit
Omar et al, 2013 [22]	69/M	Post-operative day 1 right total hip replacement, hypertension, dyslipidemia, prior surgical repair of iliac artery aneurysm	Shortness of breath, wheezing, confusion, aphasia, right-sided weakness
Ozsancak Ugurlu et al, 2015 [23]	64/F	Not mentioned	Shortness of breath, chest pain, recurrent syncope, convulsion
Barros-Gomes et al, 2018 [24]	68/F	Hypertension, tobacco abuse, COPD	Facial droop, right arm weakness, aphasia
Duy et al, 2019 [25]	53/F	Three prior ischemic strokes	Unconsciousness, dyspnea, right hemiplegia
Nam et al, 2015 [26]	69/F	Not significant	Dyspnea, drowsy mental status, right-sided hemiplegia after surgery
De Oliveira et al, 2016 [27]	41/F	Post-operative day 10 lap cholecystectomy	Dysarthria, acute respiratory distress, left calf tenderness
Dada et al, 2018 [28]	55/M	Not mentioned	Left facial droop, left-sided weakness, garbled speech
Hattori et al, 2020 [29]	68/F	History of multiple cerebral emboli, SLE on prednisolone	Dysarthria, dysphagia, left facial paralysis

Table 3. Patient Information, Risk Factors and Presenting Symptoms

Study

Age/sex

Risk factors

Presenting symptoms

COPD: chronic obstructive pulmonary disease; DVT: deep vein thrombosis; GI: gastrointestinal; HIV: human immunodeficiency virus; OCP: oral contraceptive pill; PE: pulmonary embolism; SLE: systemic lupus erythematosus.

Pelletier et al, 2010 [9]

35/F

Recent leg varicosal stripping, one spontaneous abortion, OCP use

Collapsed, altered consciousness, expressive aphasia, subtle facial asymmetry

Delgado et al, 2012 [10]

76/F

Hypertension, dyslipidemia

Sudden right leg paresis and hypoesthesia

Gunta and Kamath, 2012 [11]

16/F

Long car ride, OCP, family history of venous thromboses and PE, MTHFR mutation, antithrombin III deficiency

Unresponsive, labored respirations, shortness of breath, cough, leg pain for 2 days

Bagate et al, 2018 [12]

44/M

Psychiatric disorder

Non-shockable cardiac arrest, impaired consciousness

Lio et al, 2019 [13]

69/M

Testicular carcinoma

Signs of cardiogenic shock, questionable GI bleeding

Jayalakshmi et al, 2021 [14]

52/M

Not mentioned

Naidoo and Hift, 2011 [15]

38/F

Immobility, dilated cardiomyopathy, HIV on antiretroviral therapy

Dyspnea, pleuritic chest pain, right-sided hemiplegia

Xie et al, 2014 [16]

55/F

History of varicose veins of lower extremities

Chest distress, dyspnea, loss of consciousness, sudden non-fluent language, dyskinesis of right extremities

Christiansen et al, 2017 [17]

59/F

Post-operative day 2 abdominoplasty and liposuction, OCP

Left-sided weakness, dysarthria, acute respiratory distress

Konala et al, 2019 [18]

82/M

Type 2 diabetes mellitus, previous lower extremity DVT

Loss of consciousness while urinating, mild dyspnea before syncope

Saleh Velez and Ortiz Garcia, 2021 [19]

72/F

Not mentioned

Collapsed, comatose state, flaccid quadriplegia, cardiac arrest

Saleh Velez and Ortiz Garcia, 2021 [19]

75/F

Hypertension

Mild dysarthria, right arm paresis, severe pleuritic pain, shortness of breath

Pan et al, 2019 [20]

27/F

Post-operative day 7 C-section, Glenn anastomosis 7 years prior for cor biloculare

Dizziness, chest tightness, dysarthria, facial asymmetry, right hemiparesis

Chakir et al, 2021 [21]

60/M

Type II diabetes, COVID-19 infection

Left hemiplegia, typical anginal chest pain, hypotonia, left sensory deficit

Omar et al, 2013 [22]

69/M

Post-operative day 1 right total hip replacement, hypertension, dyslipidemia, prior surgical repair of iliac artery aneurysm

Shortness of breath, wheezing, confusion, aphasia, right-sided weakness

Ozsancak Ugurlu et al, 2015 [23]

64/F

Not mentioned

Shortness of breath, chest pain, recurrent syncope, convulsion

Barros-Gomes et al, 2018 [24]

68/F

Hypertension, tobacco abuse, COPD

Facial droop, right arm weakness, aphasia

Duy et al, 2019 [25]

53/F

Three prior ischemic strokes

Unconsciousness, dyspnea, right hemiplegia

Nam et al, 2015 [26]

69/F

Not significant

Dyspnea, drowsy mental status, right-sided hemiplegia after surgery

De Oliveira et al, 2016 [27]

41/F

Post-operative day 10 lap cholecystectomy

Dysarthria, acute respiratory distress, left calf tenderness

Dada et al, 2018 [28]

55/M

Not mentioned

Left facial droop, left-sided weakness, garbled speech

Hattori et al, 2020 [29]

68/F

History of multiple cerebral emboli, SLE on prednisolone

Dysarthria, dysphagia, left facial paralysis

**Table 4.** Descriptive Analysis of the Extracted Data From Included Studies
SD: standard deviation.
Patients, N	22
Case reports, N	20
Case series, N	1
Female, N (%)	15 (68.18%)
Male, N (%)	7 (31.82%)
Mean patient age, years	56.68 (SD: 16.8)
Median patient age, years	59.5

Table 4. Descriptive Analysis of the Extracted Data From Included Studies

SD: standard deviation.

Patients, N

Case reports, N

Case series, N

Female, N (%)

15 (68.18%)

Male, N (%)

7 (31.82%)

Mean patient age, years

56.68 (SD: 16.8)

Median patient age, years

59.5

**Table 5.** Prevalence of Main Predisposing Factors
Predisposing factors	N	%
ART: antiretroviral therapy; AT: antithrombin; COPD: chronic obstructive pulmonary disease; DVT: deep vein thrombosis; HIV: human immunodeficiency virus; OCP: oral contraceptive pill; PE: pulmonary embolism; SLE: systemic lupus erythematosus.
PE
OCP use	4	18.18
Post major surgical interventions	4	18.18
Immobility	2	9.09
Varicose veins	2	9.09
Prior lower extremity DVT	1	4.55
Family history of venous thromboses and PE	1	4.55
Homozygous for MTHFR mutation/ATIII deficiency	1	4.55
Tobacco abuse	1	4.55
COPD	1	4.55
HIV on ART	1	4.55
SLE	1	4.55
Pregnancy, especially first 6 weeks postpartum	1	4.55
Compression by mass (testicular carcinoma)	1	4.55
History of Glenn anastomosis	1	4.55
COVID-19 infection	1	4.55
Ischemic stroke
Hypertension	5	22.73
Dyslipidemia	3	13.64
Type 2 diabetes mellitus	2	9.09
Prior thromboembolic strokes	2	9.09
Tobacco abuse	1	4.55

Table 5. Prevalence of Main Predisposing Factors

Predisposing factors

ART: antiretroviral therapy; AT: antithrombin; COPD: chronic obstructive pulmonary disease; DVT: deep vein thrombosis; HIV: human immunodeficiency virus; OCP: oral contraceptive pill; PE: pulmonary embolism; SLE: systemic lupus erythematosus.

OCP use

18.18

Post major surgical interventions

18.18

Immobility

9.09

Varicose veins

9.09

Prior lower extremity DVT

4.55

Family history of venous thromboses and PE

4.55

Homozygous for MTHFR mutation/ATIII deficiency

4.55

Tobacco abuse

4.55

COPD

4.55

HIV on ART

4.55

SLE

4.55

Pregnancy, especially first 6 weeks postpartum

4.55

Compression by mass (testicular carcinoma)

4.55

History of Glenn anastomosis

4.55

COVID-19 infection

4.55

Ischemic stroke

Hypertension

22.73

Dyslipidemia

13.64

Type 2 diabetes mellitus

9.09

Prior thromboembolic strokes

9.09

Tobacco abuse

4.55

**Table 6.** Case Reports Describing Multiple Permutations of Treatment Combinations and Their Outcomes
Study	Location of PE	Treatment of PE	Location of stroke	Treatment of stroke	PFO and treatment	DVT	PFO with thrombus	Outcome
ACA: anterior cerebral artery; DVT: deep vein thrombosis; LMWH: low molecular weight heparin; ICA: internal carotid artery; IV: intravenous; IVC: inferior vena cava; MCA: middle cerebral artery; MT: mechanical thrombectomy; PE: pulmonary embolism; PFO: patent foramen ovale; rt-PA: recombinant tissue plasminogen activator.
Pelletier et al, 2010 [9]	Bilateral	Heparin infusion	Left tempoparietal	rt-PA, IVC filter	Present, closed	Negative		Marked improvement
Naidoo and Hift, 2011 [15]	Bilateral	Streptokinase	Left frontoparietal	Not treated, since neuro improved	Absent	Positive, right		Marked improvement
Delgado et al, 2012 [10]	Bilateral segmental, subsegmental	Heparin infusion	Left ACA	rt-PA	Present, not closed	Not mentioned		Marked improvement
Gunta and Kamath, 2012 [11]	Bilateral main	Heparin infusion, LMWH IVC filter	Left striatocapsular and internal capsule	MT followed by aspirin	Present, planned closure at later date	positive		Marked improvement
Omar et al, 2013 [22]	Descending trunk, right main segmental/subsegmental	IVC filter	Left MCA	MT	Present, not a candidate for PFO closure	Not mentioned		Bed-ridden and non-verbal
Ozsancak Ugurlu et al, 2015 [23]	Bilateral main into lobar branches	Percutaneous embolectomy (MT), heparin infusion	Left occipital and bilateral cerebellar lobes	Not treated	Not mentioned	Not mentioned		Marked improvement
Xie et al, 2014 [16]	Bilateral	Urokinase, LMWH, aspirin and clopidogrel	Left temporal, parietal, insular lobes and basal ganglia	Increased aspirin and clopidogrel dose	Absent	Negative		Marked improvement, recurrence of PE 10 months later
Nam et al, 2015 [26]	Bilateral	Surgical embolectomy	Left MCA and multifocal, embolic infarctions in right cerebrum	Decompressive craniectomy	Present, closed	Not mentioned	Biatrial thrombus across PFO	Long-term ventilatory support, no neuro improvement
De Oliveira et al, 2016 [27]	Not mentioned	Surgical thrombectomy	Not mentioned	Not mentioned	Present, closed	Present, left	Right atrial thrombus straddling PFO	Marked improvement
Christiansen et al, 2017 [17]	Bilateral lobar and segmental	rt-PA, LMWH, aspirin	Right MCA	rt-PA, MT	Present, not closed	Negative		Abdominal hematoma post thrombolysis, marked improvement
Barros-Gomes et al, 2018 [24]	Bilateral	MT	Left ICA	Not treated	Present, not closed	Not mentioned	Thrombus in PFO	Not reported
Bagate et al, 2018 [12]	Bilateral	Heparin infusion	Left parietal lobe	Not treated	Present, not closed	Not mentioned		Brain death
Dada et al, 2018 [28]	Main	Surgical clot removal, heparin infusion	Left temporal occipital lobe	rt-PA not given, outside window	Present, closed	Positive, right	Biatrial thrombus straddling PFO	Marked improvement
Duy et al, 2019 [25]	Bilateral	Percutaneous thrombectomy (MT), heparin infusion	Left MCA	MT	Present, anticoagulant therapy only	Negative		Marked improvement
Konala et al, 2019 [18]	Bilateral main	rt-PA, heparin infusion, IVC filter	Left caudate/putamen area	Not treated	Present, patient refused closure	Positive, bilateral	Biatrial thrombus straddling PFO	Marked improvement
Hattori et al, 2020 [29]	Bilateral main	Surg pulmonary embolectomy, IVC filter	Brain stem and left occipital lobe	Not treated	Present, closed	Positive	Thrombus straddling PFO	Marked improvement
Lio et al, 2019 [13]	Bilateral lobar	Heparin infusion	Basilar artery occlusion	MT	Present, not closed	Not mentioned		Dead
Pan et al, 2019 [20]	Left inferior and right lobar	LMWH	Left basal ganglia	Not treated	Absent	Negative		Marked improvement
Saleh Velez and Ortiz Garcia, 2021 [19]	Bilateral	Medical therapy	Right ICA	Medical therapy	Present	Negative		Dead
Saleh Velez and Ortiz Garcia, 2021 [19]	Bilateral main	Catheter-directed thrombolysis, IV heparin	Left MCA	rt-PA deferred, unknown, last time well	Present	Positive, left		Marked improvement
Jayalakshmi et al, 2021 [14]	Not mentioned	Heparin	Right MCA	Decompressive craniotomy	Not mentioned	Not mentioned		Marked improvement
Chakir et al, 2021 [21]	Bilateral	LMWH	Right MCA	Aspirin	Absent	Negative		Slight improvement in neuro

Table 6. Case Reports Describing Multiple Permutations of Treatment Combinations and Their Outcomes

Study

Location of PE

Treatment of PE

Location of stroke

Treatment of stroke

PFO and treatment

DVT

PFO with thrombus

Outcome

ACA: anterior cerebral artery; DVT: deep vein thrombosis; LMWH: low molecular weight heparin; ICA: internal carotid artery; IV: intravenous; IVC: inferior vena cava; MCA: middle cerebral artery; MT: mechanical thrombectomy; PE: pulmonary embolism; PFO: patent foramen ovale; rt-PA: recombinant tissue plasminogen activator.

Pelletier et al, 2010 [9]

Bilateral

Heparin infusion

Left tempoparietal

rt-PA, IVC filter

Present, closed

Negative

Marked improvement

Naidoo and Hift, 2011 [15]

Bilateral

Streptokinase

Left frontoparietal

Not treated, since neuro improved

Absent

Positive, right

Marked improvement

Delgado et al, 2012 [10]

Bilateral segmental, subsegmental

Heparin infusion

Left ACA

rt-PA

Present, not closed

Not mentioned

Marked improvement

Gunta and Kamath, 2012 [11]

Bilateral main

Heparin infusion, LMWH IVC filter

Left striatocapsular and internal capsule

MT followed by aspirin

Present, planned closure at later date

positive

Marked improvement

Omar et al, 2013 [22]

Descending trunk, right main segmental/subsegmental

IVC filter

Left MCA

Present, not a candidate for PFO closure

Not mentioned

Bed-ridden and non-verbal

Ozsancak Ugurlu et al, 2015 [23]

Bilateral main into lobar branches

Percutaneous embolectomy (MT), heparin infusion

Left occipital and bilateral cerebellar lobes

Not treated

Not mentioned

Marked improvement

Xie et al, 2014 [16]

Bilateral

Urokinase, LMWH, aspirin and clopidogrel

Left temporal, parietal, insular lobes and basal ganglia

Increased aspirin and clopidogrel dose

Absent

Negative

Marked improvement, recurrence of PE 10 months later

Nam et al, 2015 [26]

Bilateral

Surgical embolectomy

Left MCA and multifocal, embolic infarctions in right cerebrum

Decompressive craniectomy

Present, closed

Not mentioned

Biatrial thrombus across PFO

Long-term ventilatory support, no neuro improvement

De Oliveira et al, 2016 [27]

Not mentioned

Surgical thrombectomy

Not mentioned

Present, closed

Present, left

Right atrial thrombus straddling PFO

Marked improvement

Christiansen et al, 2017 [17]

Bilateral lobar and segmental

rt-PA, LMWH, aspirin

Right MCA

rt-PA, MT

Present, not closed

Negative

Abdominal hematoma post thrombolysis, marked improvement

Barros-Gomes et al, 2018 [24]

Bilateral

Left ICA

Not treated

Present, not closed

Not mentioned

Thrombus in PFO

Not reported

Bagate et al, 2018 [12]

Bilateral

Heparin infusion

Left parietal lobe

Not treated

Present, not closed

Not mentioned

Brain death

Dada et al, 2018 [28]

Main

Surgical clot removal, heparin infusion

Left temporal occipital lobe

rt-PA not given, outside window

Present, closed

Positive, right

Biatrial thrombus straddling PFO

Marked improvement

Duy et al, 2019 [25]

Bilateral

Percutaneous thrombectomy (MT), heparin infusion

Left MCA

Present, anticoagulant therapy only

Negative

Marked improvement

Konala et al, 2019 [18]

Bilateral main

rt-PA, heparin infusion, IVC filter

Left caudate/putamen area

Not treated

Present, patient refused closure

Positive, bilateral

Biatrial thrombus straddling PFO

Marked improvement

Hattori et al, 2020 [29]

Bilateral main

Surg pulmonary embolectomy, IVC filter

Brain stem and left occipital lobe

Not treated

Present, closed

Positive

Thrombus straddling PFO

Marked improvement

Lio et al, 2019 [13]

Bilateral lobar

Heparin infusion

Basilar artery occlusion

Present, not closed

Not mentioned

Dead

Pan et al, 2019 [20]

Left inferior and right lobar

LMWH

Left basal ganglia

Not treated

Absent

Negative

Marked improvement

Saleh Velez and Ortiz Garcia, 2021 [19]

Bilateral

Medical therapy

Right ICA

Medical therapy

Present

Negative

Dead

Saleh Velez and Ortiz Garcia, 2021 [19]

Bilateral main

Catheter-directed thrombolysis, IV heparin

Left MCA

rt-PA deferred, unknown, last time well

Present

Positive, left

Marked improvement

Jayalakshmi et al, 2021 [14]

Not mentioned

Heparin

Right MCA

Decompressive craniotomy

Not mentioned

Marked improvement

Chakir et al, 2021 [21]

Bilateral

LMWH

Right MCA

Aspirin

Absent

Negative

Slight improvement in neuro

**Table 7.** Frequencies of Treatment Approaches for PE
Treatment approach for PE	Number of cases
AC: anticoagulation; LMWH: low molecular weight heparin; IVC: inferior vena cava; MT: mechanical thrombectomy; PE: pulmonary embolism; rt-PA: recombinant tissue plasminogen activator.
Thrombolysis	5
rt-PA + AC	2
Streptokinase alone	1
Urokinase + AC	1
Catheter thrombolysis + AC	1
Heparin	6
Post rt-PA	2
Post MT	2
With craniotomy	1
Only	1
LMWH	2
Only	1
Aspirin	1
IVC filter only	1
Medical therapy only	1
Catheter-directed thrombectomy	3
MT	1
Percutaneous thrombectomy + heparin	2
Surgical approach	4
Surgical embolectomy/thrombectomy	2
Surgical pulmonary embolectomy + IVC	1
Surgical clot removal + heparin	1

Table 7. Frequencies of Treatment Approaches for PE

Treatment approach for PE

Number of cases

AC: anticoagulation; LMWH: low molecular weight heparin; IVC: inferior vena cava; MT: mechanical thrombectomy; PE: pulmonary embolism; rt-PA: recombinant tissue plasminogen activator.

Thrombolysis

rt-PA + AC

Streptokinase alone

Urokinase + AC

Catheter thrombolysis + AC

Heparin

Post rt-PA

Post MT

With craniotomy

Only

LMWH

Only

Aspirin

IVC filter only

Medical therapy only

Catheter-directed thrombectomy

Percutaneous thrombectomy + heparin

Surgical approach

Surgical embolectomy/thrombectomy

Surgical pulmonary embolectomy + IVC

Surgical clot removal + heparin

**Table 8.** Prevalence of PFO, PFO With Thrombus, and DVT in Patients With Concurrent PE and AIS
Findings	Present	Absent	Not mentioned
AIS: acute ischemic stroke; DVT: deep vein thrombosis; PE: pulmonary embolism; PFO: patent foramen ovale.
PFO	16 (72.72%)	4 (18.18%)	2
PFO with thrombus	6/16 (37.5%)
DVT	7 (31.81%)	7 (31.81%)	8

Table 8. Prevalence of PFO, PFO With Thrombus, and DVT in Patients With Concurrent PE and AIS

Findings

Present

Absent

Not mentioned

AIS: acute ischemic stroke; DVT: deep vein thrombosis; PE: pulmonary embolism; PFO: patent foramen ovale.

PFO

16 (72.72%)

4 (18.18%)

PFO with thrombus

6/16 (37.5%)

DVT

7 (31.81%)

**Table 9.** Outcomes by Treatment Modality in Patients With PE and AIS
Treatment modality	Symptom improvement and survival	Deterioration in functional status	Mortality	Not reported	Total cases
AIS: acute ischemic stroke; PE: pulmonary embolism.
Anticoagulation	5 (62.5%)	2 25.0%)	1 (12.5%)	0 (0.0%)	8
Thrombolysis	5 (100.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	5
Catheter-directed thrombectomy	2 (66.7%)	0 (0.0%)	0 (0.0%)	1 (33.3%)	3
Surgical thrombectomy	3 (75.0%)	1 (25.0%)	0 (0.0%)	0 (0.0%)	4
Treatment without anticoagulation or thrombolytic therapy	0 (0.0%)	1 (50.0%)	1 (50.0%)	0 (0.0%)	2
Total	15 (68.2%)	4 (18.2%)	2 (9.1%)	1 (4.5%)	22

Table 9. Outcomes by Treatment Modality in Patients With PE and AIS

Treatment modality

Symptom improvement and survival

Deterioration in functional status

Mortality

Not reported

Total cases

AIS: acute ischemic stroke; PE: pulmonary embolism.

Anticoagulation

5 (62.5%)

2 25.0%)

1 (12.5%)

0 (0.0%)

Thrombolysis

5 (100.0%)

0 (0.0%)

Catheter-directed thrombectomy

2 (66.7%)

0 (0.0%)

1 (33.3%)

Surgical thrombectomy

3 (75.0%)

1 (25.0%)

0 (0.0%)

Treatment without anticoagulation or thrombolytic therapy

0 (0.0%)

1 (50.0%)

0 (0.0%)

Total

15 (68.2%)

4 (18.2%)

2 (9.1%)

1 (4.5%)