No abstract

A 39-year-old female was referred to our emergency center with a consciousness disorder that got worse by the hour after hospitalization at her local hospital for a urinary tract infection 5 days prior. She had no past medical history. Physical examination revealed the following: Glasgow Coma Scale, E2V2M6; blood pressure, 90/70 mm Hg; heart rate, 110 beats/min; respiratory rate, 30 breaths/min; and body temperature, 38.0°C. White blood cell count, lactate

Objective: Acute pulmonary embolism (PE) is a life-threatening cardiovascular event associated with high mortality and morbidity. The presence of a patent foramen ovale (PFO) in patients with acute PE represents a risk factor for mortality. Furthermore, a thrombus-in-transit via a PFO with impending paradoxical embolism carries a high mortality rate.Case Presentation: An adult patient with ischemic stroke caused by paradoxical embolism following PE underwent mechanical thrombectomy and achieved successful recanalization. Initial CT pulmonary angiography (CTPA) showed not only pulmonary thromboemboli but also bilateral atrial thromboemboli. During hospitalization, transesophageal echocardiography (TEE) revealed the PFO with a right-to-left shunt. Two months after rehabilitation undergone by the patient, PE completely disappeared and PFO closure was conducted to reduce the recurrence risk of ischemic stroke. Conclusion:Not only cardiologists but also interventional neurologists should understand that CTPA can demonstrate the thrombus-in-transit through the PFO and provides a reliable prediction of the sudden onset of ischemic stroke in patients with symptomatic PE. When identified, considering a case-by-case treatment approach by multidisciplinary teams is essential for preventing further life-threatening paradoxical embolization.

Granulomatosis with polyangiitis (GPA) is the systemic vasculitis affecting predominantly small vessels, but vasculitis of medium size artery can be associated. We treated a patient with GPA who had hemorrhagic instability because of a rupture of an aneurysm in the branch of the renal artery; the patient underwent arterial embolization (AE), and hemostasis was successfully achieved. Literature reviews were conducted on the basis of the data available on PubMed, and seven published reports of eight cases with renal artery aneurysms were identified. We concluded that emergency physicians should be aware of the existence of renal artery aneurysms associated with GPA. AE should be considered as one of the treatment choices whenever renal bleeding takes place.