(1358) High-Risk PE With High-Risk TBI: The Worst of Both Worlds

Introduction: We present a case where clot progression and bleed progression became a complex balancing act.

Description: 80-year-old male presented for evaluation of a syncopal episode complicated with head trauma. Upon arrival to the emergency room, he was at 6 LPM, tachycardic to 100s, NIHSS 0. Initial imaging findings revealed bilateral pulmonary emboli with right heart strain RV/LV of 1.6:1, PESI class III and an acute subdural hematoma (SDH) along the falx cerebri.
Neurocritical care and PE team were consulted; the patient started on levetiracetam for seizure prophylaxis and on heparin infusion. Repeat CT revealed an increase in SDH, new subarachnoid hemorrhage, new hemorrhage in the high left frontal convexity, and new interventricular hemorrhage in the posterior horn of the left lateral ventricle. His NIHSS remained zero. Heparin infusion continued, tranexamic acid, desmopressin, and thromboelastograph were ordered. The following morning the patient developed right arm weakness, heparin was stopped, repeat CT head showed new hemorrhage involving the left frontal parenchyma, and worsening of previous hemorrhage sites. The patient received 1U of cryoprecipitate because his Macff = 13.8 with decreased FLEV. At this point the patient’s right arm was flaccid, right lower extremity 2/5 power, and developed right hemineglect. Per interventional cardiology patient was not a candidate for catheter-directed lysis or thrombectomy. NIHSS at 13, the patient was given a dose of Protamine 25 mg IV once. He was to be started on anticoagulation with apixaban 2.5mg after 10 days.

Discussion: Most cases and systemic reviews discuss pulmonary embolisms following acute intracerebral hemorrhage after neurosurgical intervention. Our case is a reverse scenario. A prospective multicenter study, evaluating the progression of intracranial bleed after starting anticoagulation therapy reported 9.6% experienced clinically significant lesion progression after anticoagulant therapy, of whom 9 (5.4%) patients needed subsequent neurosurgical interventions ​
Most reported cases discuss PE secondary to immobilization from ICB/neuro-interventional and even for those there is no conclusive evidence for time of starting anticoagulant​. Furthermore, no data exists regarding the frequency of surveillance imaging.