# When a Pulmonary Embolism Precedes the Fall: Anticoagulation Challenges in Traumatic Intracranial Hemorrhage

## TL;DR

This paper discusses the challenges of managing a patient with both a severe blood clot in the lungs and a head injury, where anticoagulation must be carefully balanced to avoid worsening bleeding.

## Contribution

The paper presents a novel case management approach for concurrent pulmonary embolism and traumatic intracranial hemorrhage using mechanical thrombectomy and staged anticoagulation.

## Key findings

- A 74-year-old patient with massive PE and traumatic ICH was successfully managed with mechanical thrombectomy and cautious anticoagulation.
- Staged anticoagulation and multidisciplinary collaboration allowed safe re-initiation of therapy without neurological deterioration.
- Serial imaging confirmed stability after initial hemorrhage progression, supporting the effectiveness of the treatment strategy.

## Abstract

Pulmonary embolism (PE) is typically managed with urgent systemic anticoagulation or reperfusion therapy. However, management becomes complex when PE occurs concurrently with traumatic intracranial hemorrhage (ICH), where anticoagulation may worsen bleeding.

A 74-year-old male patient presented after syncope and traumatic head injury. He was hypoxic and tachycardic on arrival with concern for right ventricular strain. Given persistent clinical concern, CT angiography of the chest demonstrated a massive saddle PE. CT of the head revealed traumatic subarachnoid hemorrhage and a small subdural hematoma with an occipital skull fracture, with no midline shift/mass effect, and an admission Glasgow Coma Scale (GCS) of 15/15. He underwent urgent mechanical thrombectomy with inferior vena cava (IVC) filter placement. A cautious heparin infusion was initiated without a bolus following neurosurgical approval and close neurological monitoring. Early repeat CT demonstrated interval hemorrhage progression, but subsequent imaging showed stability. His activated partial thromboplastin time (aPTT) was titrated carefully without clinical deterioration, and he was transitioned to apixaban without a loading dose. He remained neurologically stable and improved clinically prior to discharge.

This case illustrates the competing priorities of preventing fatal thromboembolism while minimizing hemorrhagic progression in traumatic ICH. Mechanical thrombectomy, serial imaging, and staged anticoagulation guided by multidisciplinary collaboration allowed safe re-initiation of anticoagulation.