The management of established pulmonary thromboembolism (PTE) coexisting with acute ischemic stroke (AIS) is quite challenging. We report the case of a 52-year-old man with concurrent massive right middle cerebral artery AIS and acute PTE, who was successfully managed despite the contradictory guidelines to manage them simultaneously. The patient underwent decompression craniotomy followed by anticoagulant therapy. The current case report demonstrates that full-dose heparin, despite being relatively contraindicated in an AIS, can achieve a good outcome when given under close monitoring. The transesophageal echo with bubble contrast during the Valsalva maneuver demonstrated patent foramen ovale with a right to left shunt as a cause of AIS and PTE in this patient.
Keywords: Acute ischemic stroke; patent foramen ovale; pulmonary thromboembolism.