Eltrombopag, a thrombopoietin receptor agonist, has been linked to an increased risk of thromboembolic events. However, large vessel occlusion and massive pulmonary emboli (PE) associated with its use have not been reported in the literature. We present a case of a 62-year-old man who developed acute ischemic stroke due to large vessel occlusion and simultaneous bilateral massive PE while receiving eltrombopag for stage IV pancreatic cancer. 

A 62-year-old male with diabetes, end-stage renal disease, and stage IV pancreatic cancer on eltrombopag for chemotherapy-induced pancytopenia, presented with acute ischemic stroke as a candidate for endovascular thrombectomy (EVT). After initially presenting at an outside hospital with breathlessness and hemodynamic instability, he underwent CTA chest which revealed bilateral PE. He subsequently developed right-sided hemiplegia and aphasia (NIHSS score 20), with imaging showing left M1 MCA occlusion and subarachnoid hemorrhage. Upon transfer to our facility, DSA confirmed these findings, and mechanical thrombectomy achieved partial recanalization (Pre-EVT TICI 0; Post EVT TICI 2b). Due to worsening hemodynamic instability from the PE, transthoracic echocardiogram (TTE) was performed which revealed significant right ventricular dysfunction with McConnell sign. Continuous IV heparin was initiated due to his critical cardiopulmonary status despite elevated intracranial hemorrhage risk. The patient’s hemodynamic parameters worsened and catheter-director thrombolysis with EKOS was pursued, improving oxygenation and decreasing right ventricular strain. Following clinical stabilization, Dual-Energy CT (DECT) was performed to differentiate contrast extravasation from hemorrhagic transformation which confirmed subarachnoid hemorrhage without significant hemorrhagic transformation, allowing continuous anticoagulation. Neurologically, his aphasia and right-sided strength improved (MRC 3/5). Despite improvement, the family opted for comfort measures due to his poor prognosis from metastatic cancer. 

This case highlights the role of advanced imaging like DECT and individualized therapeutic strategies in balancing treatment benefits against potential complications for patients with significant thrombosis and intracranial hemorrhage risks.