Seizures as the first clinical manifestation of acute pulmonary embolism: an underestimate issue in neurocritical care

The aim of the present review is to analyze the clinical characteristics of patients with acute pulmonary embolism (PE) which seizures were the first clinical manifestation of the disease. After screening 258 articles in PubMed, Scopus, Cochrane Library, and Google Scholar databases, we identified 16 case reports meeting the inclusion criteria. The mean age of the population was 48.4 ± 19.8 years (9 males and 7 females). About three of four patients (68.7%) were hemodynamically stable at admission, having a systolic blood pressure > 90 mmHg. Intriguingly, the doubt of acute PE was based on clinical suspicion or on instrumental findings in 62.5% and 18.7% of patients, respectively. In 3 subjects (18.7%), the acute cardiovascular disease was not suspected. Half of patients had an unremarkable previous medical history while neurological comorbidities were present in 4 patients (25.0%). During seizures, a transient loss of consciousness (TLOC) was reported in 6 cases. Seizures were retrospectively classified according to the 2017 ILAE classification, whenever possible. A focal and generalized onset was reported in 37.5% and 50% of cases, respectively, in 12.5% of patient’s data that were insufficient to classify the events. The mean number of seizure episodes in the population enrolled was 2.0 ± 1.1. Mortality rate was 54.5% but one investigation did not report the patient’s outcome. The relationship between seizures and acute PE is probably underrecognized. Identifying patients that have a high probability of acute PE is fundamental to avoid any treatment delay and ameliorate their outcomes.