case_images: PMC6036529_01
case_images: Trans-thoracic Echocardiography showing severe right ventricular (RV) enlargement and high pulmonary artery pressure (PASP: 45 mmHg
case_images: emerg-6-e25-g001.jpg
case_images: PMC6036529_01_emerg-6-e25-g001.jpg
case_images: F1
case_images: Trans-thoracic echocardiography (Figure 1.1) revealed severe RV dilation and moderate RV dysfunction with moderate tricuspid regurgitation and elevated pulmonary artery systolic pressure (pulmonary artery systolic pressure (PASP): 45 mmHg). A chest computed tomography (CT) scan showed a wedge consolidation in left lower lobe of lung (Figure 1.2 left). According to the above findings, PE was diagnosed for the patients and chest CT angiography was done, which demonstrated a large filling defect in main pulmonary artery and both main bronchi (Figure 1.2 right). In brain CT scan, hemorrhagic transformation in territory of prior CVA was reported (Figure 1.3 left). Pulmonary CT angiography was done 24 hours after treatment and showed reduction of thrombus bulk and RV size (Figure 1.4). Two control brain CT scans (4 h and 24 h after treatment) didn't show any new intracranial hemorrhage (figure 1.3 right).
case_images: PMC6036529_02
case_images: Left: Chest computed tomography (CT) image showing a wedge consolidation in left lower lobe of lung, Right: Chest CT Angiography demonstrating large filling defect in main pulmonary artery and both main bronchi
case_images: emerg-6-e25-g002.jpg
case_images: PMC6036529_02_emerg-6-e25-g002.jpg
case_images: F2
case_images: The findings of CT angiography (figure 2.1) confirmed Saddle embolism in pulmonary arteries (filling defects in main, left and right pulmonary artery).
case_images: PMC6036529_03
case_images: Brain CT scan before (Left) and after (Right) fibrinolysis showing hemorrhagic transformation in territory of prior CVA without change
case_images: emerg-6-e25-g003.jpg
case_images: PMC6036529_03_emerg-6-e25-g003.jpg
case_images: F3
case_images: The initial electrocardiogram showed sinus tachycardia at a rate of 135 per minute, right bundle branch block with a QRS duration of 125 milliseconds and right axis deviation of 120 degrees (figure 3.1). Pulmonary CT angiography confirmed large bilateral pulmonary thromboembolic (saddle-shaped embolism with obstruction of 85% of the arterial substrate) with radiological evidence of RV strain (figure 3.2).  Electrocardiogram then showed sinus tachycardia at a rate of 125 per minute, normal QRS duration and normal axis (Figure 3.3).