Dr. Beaumont Health Royal oak, Michigan, United States
Introduction: The mortality of intermediate to high-risk pulmonary embolism is significant and warrants treatment with anticoagulation. Here we describe a case of acute PE in a patient with recent basal ganglia bleed.
Description: A 77-year-old man with uncontrolled hypertension, and peripheral vascular disease presented with left upper and lower extremity weakness. Head CT revealed an acute area of hemorrhage with the epicenter in the right basal ganglia measuring approximately 3.1 x 2.1 cm with surrounding edema. CT angiography of head and neck showed normal arterial circulation. Neurosurgery team did not recommend any surgical intervention. He was admitted to the medical intensive care unit for monitoring of neurological and hemodynamic status. Aspirin was held and he received desmopressin with intravenous antihypertensive medications. Repeat head CT showed stable hemorrhage and edema. He was transferred to an inpatient rehabilitation unit. The patient later had worsening hypoxia. CT angiography revealed extensive bilateral pulmonary emboli within the distal main pulmonary arteries extending into the lobar, segmental, and subsegmental branches throughout both lungs. RV/LV ratio was noted to be approximately 0.80. Bilateral lower extremity venous doppler ultrasound revealed left acute deep vein thrombosis of left common femoral veins, femoral vein and popliteal vein. Patient underwent emergent mechanical thrombectomy and inferior vena cava filter placement. Post-procedure he required 100% FiO2 on heated high-flow oxygen. Given the patient's extensive clot burden, evidence of right ventricular strain on echocardiogram and CT scan as well as troponin elevation, question was raised about the risk versus benefit of using anticoagulation. Neurosurgery recommended starting anticoagulation with close monitoring of his neurological status and repeat imaging within 24 hours, which showed stable intracranial hemorrhage. His oxygen status improved for 2-3 days after which it worsened, due to aspiration pneumonia. He was started on broad-spectrum antibiotics and continued to receive ICU-level care.
Discussion: Anticoagulation after a history of a hemorrhagic stroke poses a therapeutic dilemma. Our case highlights that mechanical thrombectomy may not be solely relied upon in patients with extensive clot burden.
