Title Management of Massive Pulmonary Embolism after Intraparenchymal Hemorrhage with Mechanical Thrombectomy Introduction
Simultaneous intraparenchymal hemorrhage (IPH) and pulmonary embolism (PE) present a therapeutic dilemma because of hemorrhagic and thrombotic risks. Management options are limited given that IPH is an absolute contraindication to standard therapy. We present a case of a patient with spontaneous IPH followed by massive PE leading to cardiac arrest and was successfully treated with emergent mechanical thrombectomy while utilizing continuous non-bolus heparin infusion.
Clinical Case
58-year-old male with past medical history of untreated hypertension was brought to the emergency department for right-sided hemiplegia and aphasia for an unknown duration. Initial assessment revealed hypertension (202/110), and computed tomography (CT) head showed acute IPH in the posterior left basal ganglia. He was admitted to the neurointensive care unit for medical management of hypertensive emergency. A repeat head CT demonstrated stability 24 hours after admission, and he was started on chemical thromboprophylaxis. On hospital day 8, he developed right-sided chest pain for which initial work-up was unremarkable, including negative troponins, stable electrocardiogram, and unchanged limited transthoracic echocardiogram. He later developed bradycardia and became unresponsive, prompting intubation for failure to protect his airway. After completing a CT pulmonary angiogram (CTPA), he had recurrent episodes of bradycardia with administration of 1mg of atropine, leading to pulseless electrical activity (PEA) arrest. He underwent three cycles of advanced cardiovascular life support and 2 mg intravenous epinephrine with the return of spontaneous circulation. CTPA resulted with bilateral saddle pulmonary embolism with right heart strain. Given continued clinical deterioration with vasopressor requirements of 130 mcg/min of norepinephrine and multiple boluses of epinephrine to maintain marginal blood pressures, interventional cardiology proceeded with emergent mechanical thrombectomy on non-bolus heparin anticoagulation. Large-bore aspiration thrombectomy (FlowTriever Retrieval/Aspiration) was successful, followed by the deployment of an IVC filter with a total procedure time of 21 minutes. He was weaned from inotropic support and repeat head imaging was negative for new or worsening hemorrhage once heparin reached therapeutic level. However, on hospital day 17, the patient became less responsive, prompting repeat head CT. This showed an interval increase in IPH, new significant local mass effect, and left to right midline shift. Heparin drip was reversed with protamine. He was placed on prophylactic anticoagulation and ultimately discharged after 37 days in the hospital to inpatient rehab on daily 40 mg subcutaneous Enoxaparin until clearance by neurosurgery outpatient.
Discussion
PE is a life-threatening condition with devastating complications, including cardiac arrest secondary to right ventricular failure. Patient presentations are variable and include chest pain, dyspnea, and tachycardia. Diagnosis is based on CTPA. Management options include anticoagulation, systemic thrombolysis, catheter-directed interventions, and surgical embolectomy. Nevertheless, contraindications such as bleeding risks can limit their use because IPH is a feared complication. This case's complexity stemmed from the coexisting IPH, necessitating the prevention of thrombus propagation without exacerbating bleeding. In select patients, mechanical thrombectomy with non-bolus heparin infusion emerges as a lifesaving alternative by providing a balance between preventing clot formation and minimizing bleeding risk.