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Treatment of a massive pulmonary embolism using pulse‐spray thrombolysis in a patient with central nervous system infection: a risk or the adequate choice?

Sir, Massive and sub-massive pulmonary embolism is a lifethreatening disorder requiring a more aggressive therapy than anticoagulation (1). These methods of treatment include thrombolysis, open surgical embolectomy and multiple minimally invasive procedures involving catheter-directed methods, percutaneous embolectomy and thrombus fragmentation (2,3). The choice of the best way is difficult and requires the evaluation of severity of the disease, absolute and relative contraindications to thrombolysis and also the experience of the local cardiac surgery and radiological team. However, studies comparing these methods are lacking. A 53-year-old woman was admitted to our ICU because of cardiogenic obstructive shock caused by a massive pulmonary embolism requiring continuous delivery of epinephrine (0.13 mg/kg/min). Echocardiography revealed severe right ventricular dysfunction and extensive occlusion in most of the pulmonary artery branches was confirmed by CT pneumoangiography. Hence, the clinical as well as imaging findings fulfilled an indication for aggressive interventional therapy such as thrombolysis. However, at the same time the patient was treated for severe tick-borne flavivirus encephalitis for 10 days, being the ninth day from the lumbar puncture. Surprisingly, no data regarding the safety of thrombolytic therapy in patients suffering from central nervous system (CNS) infectious disease are available in the literature. Nevertheless, in the presence of significant, acute CNS inflammation, we considered systemic thrombolysis as potentially risky. Because the surgical embolectomy was not indicated by an experienced surgeon, a decision was made to perform one of the minimally invasive methods with topical administration of a smaller amount of the thrombolytic agent, namely pulse-spray thrombolysis. Having inserted the catheter, the radiologist applied 35 mg of tissue plasminogen activator (t-PA) to the left main pulmonary artery branch followed by a continuous low dose (1 mg/h) infusion of t-PA for the next 12 h. Marked hemodynamic improvement was reached within 3 h from the initiation of the procedure enabling catecholamines withdrawal. The control angiography performed after that period showed almost complete re-canalization. The catheter was then repositioned in the right branch and administration of t-PA (1 mg/h) continued for another 24 h, aimed at dissolving the remaining mural thrombi. As a result, the outstanding outcome was reached comprising rapid clinical improvement and normal echocardiography without any bleeding complications. To our knowledge, this is the first report on the successful and safe alternative method for the treatment of massive pulmonary embolism in the course of CNS inflammatory disease. We hope our case report can assist in the difficult decision making in this life-threatening disorder requiring a rapid, effective and safe treatment.