Submassive Pulmonary Embolism in the Setting of Intracerebral Hemorrhage: A Case of Suction Thrombectomy

Abstract

Pulmonary embolism (PE) in the setting of intracerebral hemorrhage (ICH) is an unfortunate, challenging, and highly morbid clinical problem. Interventional strategies have lower associated bleeding risks than the standby for PE treatment: systemic anticoagulation. Despite this benefit, there are few examples in the literature of its utilization in the management of PE in the setting of ICH. This present case provides an example of the successful utilization of suction thrombectomy to manage PE in the setting of ICH. An 80-year-old female presented to an outside hospital with complaints of dizziness, headache, nausea, and vomiting of abrupt onset one hour before arrival. Computed tomography (CT) of the head with CT Angiography (CTA) of the head and neck was performed and demonstrated hemorrhage in all ventricles; most prominently within the left lateral ventricle. Magnetic Resonance Imaging (MRI) 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. Ten days after her diagnosis of ICH, a submassive PE was diagnosed with a class IV pulmonary embolism severity index (PESI). An interdisciplinary evaluation was conducted between hospitalist medicine, neurology, neurosurgery, and interventional radiology. A successful suction thrombectomy was performed on hospital day 11. No new neurologic deficits were appreciated post-procedure. The patient's heart rate remained elevated but improved. Blood pressure remained controlled. The patient was weaned off oxygen to room air. Neurosurgery assessed the patient to be of acceptable risk for discharge with the further deferment of anticoagulation until repeat CT head six weeks after discharge. The patient was discharged on hospital day 14. Treating PE in the setting of ICH is without clear guidelines. The appropriate treatment modality is reliant upon the clinical judgment and the individual details of each case. In this case, a high PESI with imaging demonstrating a stable hematoma without evidence of new blood resulted in the decision to use a suction thrombectomy. More research is needed to develop consistent evidence-based guidelines for this clinical challenge.

Keywords: intracerebral hemorrhage; pulmonary embolism; stroke; submassive; thrombectomy; thrombosis.

Figure 1. Axial CT (bottom) with sagittal (right) and coronal (left) multiplanar reformatting demonstrating hemorrhage in the bilateral lateral ventricles, third ventricle, and fourth ventricle. There is a tiny focus of hemorrhage in the periventricular white matter adjacent to the high convexity left lateral ventricle. Also seen is mild dilatation of the lateral ventricles.

Figure 2. Axial diffusion-weighted MRI of the head/brain WWO IV contrast demonstrating a small focus of diffusion restriction within the white matter abutting the left lateral ventricle consistent with acute infarction.

Figure 3. Axial helical CT performed following 75 mL of Isovue-370 IV contrast with multiplanar reconstructions demonstrating filling defects in the distal right main pulmonary artery extending into the lobar branches of the upper and lower lobes and subsegmental branches of the right middle lobe. There is a filling defect in the distal left main pulmonary artery extending into the lobar branches of the upper and lower lobes. No disproportionate right ventricular dilation.

Figure 4. Axial CT (bottom) of the head without contrast, including sagittal (left) and coronal (right) multiplanar reformatted images, demonstrated interval evolution and continued resolution of the interventricular hemorrhage. The majority of the intraventricular blood is hypoattenuating to normal brain tissue and has largely resolved. Blood within the third and fourth ventricles is less conspicuous compared to the prior MRI. There is a small focus on intraparenchymal hemorrhage that remains just superior to the left basal ganglia which are evolving but not enlarging. Lateral ventricles have decreased in size.