Limits...
Therapeutic Dilemmas Regarding Anticoagulation: An Experience in a Patient with Nephrotic Syndrome, Pulmonary Embolism, and Traumatic Brain Injury

View Article: PubMed Central - PubMed

ABSTRACT

Patients with active bleeding complications who concomitantly develop overt pulmonary embolism (PE) present distinct therapeutic dilemmas, since they are perceived to be at substantial risk for the progression of the embolism in the absence of treatment and for aggravation of the hemorrhagic lesions if treated with anticoagulants. A 76-year-old patient with nephrotic syndrome, which is associated with an increased risk of thromboembolism, concurrently developed acute PE and intracranial bleeding because of traumatic brain injury. In this case, we prioritized the treatment for PE with the intravenous unfractionated heparin followed by warfarinization. Despite the transient hemorrhagic progression of the brain contusion after the institution of anticoagulation, our patient recovered favorably from the disease without any signs of neurological compromise. Several conundrums regarding anticoagulation that emerged in this case are also discussed.

No MeSH data available.


Related in: MedlinePlus

The findings of chest CT angiogram. An initial study (A and B) shows intraluminal thrombi in the main pulmonary arteries (arrows), while no filling defects are demonstrated in the repeat study (C and D).
© Copyright Policy - open-access
Related In: Results  -  Collection


getmorefigures.php?uid=PMC5096764&req=5

f2-ccrep-9-2016-103: The findings of chest CT angiogram. An initial study (A and B) shows intraluminal thrombi in the main pulmonary arteries (arrows), while no filling defects are demonstrated in the repeat study (C and D).

Mentions: The patient was in a good state during the 26-hour post-procedural bed rest without the use of any kind of sequential compression devices, while she suddenly fainted and collapsed just after the first ambulation, resulting in falling backward and striking the back of her head. A few minutes later, her consciousness fully recovered spontaneously with a blood pressure of 131/85 mmHg when she displayed tachypnea with an oxygen saturation below 90% while breathing ambient air. She was then started on a non-rebreather mask with an oxygen reservoir bag flowing at 10 L/minute. Urgent brain computed tomography (CT) showed subarachnoid hemorrhaging with a left frontal subdural hematoma (Fig. 1A), and subsequent contrast-enhanced diagnostic CT revealed bilateral thrombosis of the pulmonary arteries (Fig. 2A and B), despite the absence of venous filling defects in the abdominal veins and the lower limbs. An urgent laboratory analysis revealed a platelet count of 13.7 × 104/µL and d-dimer of 51.2 µg/mL, while echocardiogram revealed right ventricular enlargement with an increased estimated pulmonary artery systolic pressure of 55 mmHg. We then decided to prioritize the treatment of the PE under multidisciplinary collaboration involving cardiologists and neurosurgeons. Intravenous unfractionated heparin was resumed just after the radiological confirmation of the diseases, and the patient was transferred to the intensive care unit for close monitoring of her clinical status.


Therapeutic Dilemmas Regarding Anticoagulation: An Experience in a Patient with Nephrotic Syndrome, Pulmonary Embolism, and Traumatic Brain Injury
The findings of chest CT angiogram. An initial study (A and B) shows intraluminal thrombi in the main pulmonary arteries (arrows), while no filling defects are demonstrated in the repeat study (C and D).
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC5096764&req=5

f2-ccrep-9-2016-103: The findings of chest CT angiogram. An initial study (A and B) shows intraluminal thrombi in the main pulmonary arteries (arrows), while no filling defects are demonstrated in the repeat study (C and D).
Mentions: The patient was in a good state during the 26-hour post-procedural bed rest without the use of any kind of sequential compression devices, while she suddenly fainted and collapsed just after the first ambulation, resulting in falling backward and striking the back of her head. A few minutes later, her consciousness fully recovered spontaneously with a blood pressure of 131/85 mmHg when she displayed tachypnea with an oxygen saturation below 90% while breathing ambient air. She was then started on a non-rebreather mask with an oxygen reservoir bag flowing at 10 L/minute. Urgent brain computed tomography (CT) showed subarachnoid hemorrhaging with a left frontal subdural hematoma (Fig. 1A), and subsequent contrast-enhanced diagnostic CT revealed bilateral thrombosis of the pulmonary arteries (Fig. 2A and B), despite the absence of venous filling defects in the abdominal veins and the lower limbs. An urgent laboratory analysis revealed a platelet count of 13.7 × 104/µL and d-dimer of 51.2 µg/mL, while echocardiogram revealed right ventricular enlargement with an increased estimated pulmonary artery systolic pressure of 55 mmHg. We then decided to prioritize the treatment of the PE under multidisciplinary collaboration involving cardiologists and neurosurgeons. Intravenous unfractionated heparin was resumed just after the radiological confirmation of the diseases, and the patient was transferred to the intensive care unit for close monitoring of her clinical status.

View Article: PubMed Central - PubMed

ABSTRACT

Patients with active bleeding complications who concomitantly develop overt pulmonary embolism (PE) present distinct therapeutic dilemmas, since they are perceived to be at substantial risk for the progression of the embolism in the absence of treatment and for aggravation of the hemorrhagic lesions if treated with anticoagulants. A 76-year-old patient with nephrotic syndrome, which is associated with an increased risk of thromboembolism, concurrently developed acute PE and intracranial bleeding because of traumatic brain injury. In this case, we prioritized the treatment for PE with the intravenous unfractionated heparin followed by warfarinization. Despite the transient hemorrhagic progression of the brain contusion after the institution of anticoagulation, our patient recovered favorably from the disease without any signs of neurological compromise. Several conundrums regarding anticoagulation that emerged in this case are also discussed.

No MeSH data available.


Related in: MedlinePlus