An 80 year old female presented to an outside hospital with complaints of dizziness, headache, nausea, and vomiting of abrupt onset one hour prior to arrival. Computed tomography (CT) of the head with CT Angiography (CTA) of the head and neck was performed and demonstrated hemorrhage (ICH) in all ventricles; most prominently within the left lateral ventricle (Figure 1). Patient’s past medical history is significant for systemic hypertension, non-insulin dependent type 2 diabetes mellitus, chronic obstructive pulmonary disease, and permanent atrial fibrillation anticoagulated with rivaroxaban. Prothrombin complex concentrate was administered for reversal of her anticoagulation and the patient was transferred to this present facility for neurosurgical evaluation and management. Neurosurgery assessed medical management to be appropriate for this patient and she was admitted to the intensive care unit (ICU). Her ICU course was complicated by hypertensive urgency managed with a nicardipine drip. She also experienced atrial fibrillation with rapid ventricular response managed with a diltiazem drip. CT head 48 hours after presentation was with stable parenchymal and intraventricular hemorrhage. Patient’s level of care was deescalated to the medical wards and patient was transferred with blood pressures controlled off titratable medication. She would continue to be with a rapid ventricular response.
Magnetic Resonance Imaging (MRI) (Figure 2) of the brain suggested that the cause of her hemorrhage was reperfusion injury after a small acute infarction in the left internal capsule in the setting of anticoagulant use. Patient remained relatively stable until hospital day nine. At that time, on intermediate care, patient was found in hypoxemic respiratory failure requiring oxygen support with low flow nasal canula as high as five liters. In the days leading up to this acute hypoxemia, patient had been started on ceftriaxone and azithromycin given concerns for pneumonia in the setting of leukocytosis, hypoxemia requiring a two liter low flow nasal canula, and nonspecific retrocardiac opacity on chest x-ray. Antibiotic therapy was escalated to cefepime and vancomycin due to the acute worsening of her hypoxemia. Azithromycin was discontinued with negative urine antigen tests for streptococcus pneumoniae and legionella pneumophila. CTA of the chest was ordered with concern for pulmonary embolism. This testing would demonstrate bilateral lobar, segmental, and subsegmental pulmonary emboli (Figure 3). No evidence of right heart strain on CTA but High Sensitivity Troponin was elevated to 249.1 ng/L. Subsequent ultrasonography of her lower extremities was without deep vein thrombosis bilaterally. This finding would come ten days after her diagnosis of ICH.
An interdisciplinary evaluation was conducted between hospitalist medicine, neurology, neurosurgery, and interventional radiology. Head CT was repeated and demonstrated continued evolution of the ICH without expansion nor new hemorrhage identified (Figure 4). Neurology assessed that systemic anticoagulation would be too high risk to consider at this juncture. Interventional Radiology was consulted onto the case. The patient was normotensive, with positive heart enzymes but no evidence of right heart strain on CT scan nor electrocardiogram, and therefore assessed to have submassive, low-intermediate risk PE. Echocardiography was not performed. However, given her persistent heart rates into the 120s in the setting of concomitant atrial fibrillation and persistent oxygen desaturations into the 80s while on five liter nasal canula, there was concern for eventual hemodynamic decompensation. Her Pulmonary Embolism Severity Index (PESI) was assessed as class IV, High Risk with 4.0-11.4% 30-day mortality, given her heart rates and oxygen saturations. A suction thrombectomy was proposed. This would require therapeutic anticoagulation but only for the two-hour duration of the procedure. An inferior vena cava filter (IVC) would also be placed. The proposed treatment was discussed with neurosurgery who assessed that the risk of not treating outweighed the risk of expansion of her ICH in the brief period of anticoagulation anticipated. Successful suction thrombectomy was performed on hospital day 11. 150 units of heparin were administered during the procedure. Pulmonary artery pressures improved from 61/25 mmHg pre-procedure to 47/27 mmHg post-procedure. IVC filter was placed without complication.
No new neurologic deficits were appreciated post-procedure. Patient’s heartrates remained elevated by improved. Blood pressures remained controlled. Patient was weaned off oxygen to room air. Neurosurgery assessed patient to be of acceptable risk for discharge with further deferment of anticoagulation until repeat CT Head six weeks after discharge. Patient was discharged on hospital day 14.