Abstract Introduction Acute pulmonary embolism (PE) can lead to pulmonary infarction, often visualized as a wedge-shaped opacity on imaging due to occlusion of a distal pulmonary artery and subsequent necrosis. Management typically centers on prompt anticoagulation, and it becomes complex in patients with recent intracranial hemorrhage. This case highlights the importance of interdisciplinary team approach in decision-making in such complex scenarios, where cautious anticoagulation and mechanical thrombectomy were used to achieve management. Case Presentation A 63-year-old man with atrial fibrillation, alcohol use disorder, and a prior subdural hemorrhage managed conservatively, presented with several days of hemoptysis, dyspnea, and pleuritic left-sided chest pain. On arrival to the outside hospital (OSH), initial vital signs were significant for tachycardic heart rate (∼190 bpm), normotensive blood pressure, tachypnea, and oxygen saturation 90% on room air. Electrocardiogram revealed atrial fibrillation with rapid ventricular response. Initial NT-proBNP was 1,127 pg/ml and Troponin-T, High Sensitivity was 28 ng/L. CT chest demonstrated extensive bilateral pulmonary emboli with left lower-lobe ground-glass opacities, some with wedge-shaped appearance. CT head showed stable chronic bilateral subdural collections. Given his recent intracranial bleed, neurosurgery was consulted and recommended a heparin infusion without bolus, and serial CT head imaging planned once therapeutic levels were reached. The patient was transferred to a tertiary care center for consideration of advanced therapies, and he was intubated in advance of procedure. Echocardiogram revealed preserved left ventricular function and no significant right ventricular strain. Surveillance head imaging remained stable. Given that his intermediate high risk pulmonary embolism was contributing to his respiratory failure, he underwent successful aspiration thrombectomy of the right and left pulmonary arteries with retrieval of significant subacute/chronic appearing clots. He also underwent successful placement of Cook Select IVC filter. Discussion This case illustrates the diagnostic and therapeutic challenges of managing acute PE in a patient with recent intracranial hemorrhage. The presence of wedge-shaped pulmonary opacities should raise suspicion for pulmonary infarction secondary to embolic occlusion. In such cases, multidisciplinary collaboration between neurosurgery, cardiology, and critical care is essential to balance the competing risks of thrombosis and hemorrhage. Cautious anticoagulation with heparin, guided by serial neuroimaging, allowed safe initiation of therapy in this high-risk context. Additionally, using advanced endovascular techniques, such as mechanical thrombectomy in this case, effectively restores blood flow. Clot removal can significantly improve outcomes, as it directly addresses the embolism and restores pulmonary perfusion. This abstract is funded by: None
Park et al. (2026) studied this question.