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

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.