Pulmonary embolism after brain hemorrhage in a hypertensive patient: the therapeutic dilemma

Management of intraoperative acute pulmonary embolism in a patient with subarachnoid haemorrhage undergoing femoral fracture repair

Acute pulmonary embolism (APE) during surgery can be life-threatening. We herein report a case of a 56-year-old man with subarachnoid haemorrhage who underwent surgical repair of a femoral fracture. During surgery with the patient under general anaesthesia, his oxygen saturation and end-tidal carbon dioxide decreased dramatically. An emergency transoesophageal echocardiogram demonstrated mobile echogenic densities in the right pulmonary artery and enlargement of the right atrium, and these findings were suggestive of APE. Considering the patient’s history of subarachnoid haemorrhage, anticoagulation with heparin or thrombolysis therapy for APE was contraindicated. We recommended inferior vena cava filter placement to prevent recurrence of the APE. Unfortunately, the patient and his family members refused the filter implantation, and the patient was discharged.

Management of pulmonary embolism after recent intracranial hemorrhage: A case report

RATIONALE

Venous thromboembolism may result from prolong immobilization following intracerebral hemorrhage. Massive pulmonary embolism with associated right heart failure is life-threatening, requiring treatment with anticoagulants or even thrombolytic agents. However, these drugs are contraindicated after a recent hemorrhagic episode, as they may induce further hemorrhage. There are no guidelines for treatment in these circumstances.

PATIENT CONCERNS

A 57-year-old man experienced massive pulmonary embolism and shock 18 days after an intracerebral hemorrhage.

DIAGNOSES

Tachycardia and high D-dimer (21.27 mg/L fibrinogen-equivalent units) were noted. Chest computed tomography showed bilateral pulmonary trunk embolism.

INTERVENTIONS

Heparinization were used and activated partial thromboplastin time therapeutic range was 50 to 70 seconds. Fortunately, shock status and shortness of breath improved two days later. Continuing high dose Rivaroxaban was administrated for three weeks.

OUTCOMES

There was no recurrent intracranial hemorrhage (ICH) following treatment for three-weeks with high-dose and one-year with standard dose of rivaroxaban. This report presents a treatment option in the management of these difficult clinical situations.

LESSONS

The combination of unfractionated heparin infusion and continuing non-Vitamin K antagonist oral anticoagulants use could manage life-threatening pulmonary embolism following recent ICH. Theoretically, the use of NOAC is a safer strategy if the patient with previous history of major ICH.