Therapeutic Challenge in a Case of Extensive Pulmonary Embolism with Concomitant Intracranial Haemorrhage: When Less is Really More.

Pulmonary embolism is a conundrum that clinicians often need to grapple with when managing patients with recent intracranial hemorrhage (ICH). A 50-year-old woman was admitted to the medical ward for left basal ganglia hemorrhage caused by a hypertensive emergency with resultant dense right hemiparesis. The ICH was managed conservatively by neurosurgical team. On day 9 of admission, the patient developed acute respiratory distress that required high-flow nasal cannula support. Her D-dimer level was increased with bedside ultrasonography revealing right heart strain patterns that warranted empirical pulmonary embolism (PE) treatment. Balancing the risk of ICH expansion and imminent respiratory collapse, she was empirically treated with intermediate dose low molecular weight heparin (LMWH) while awaiting CT pulmonary angiogram (CTPA) examination. CTPA confirmed the diagnosis of extensive PE with right lower lobe pulmonary infarction. Subsequent serial brain CT showed steady resolution of the ICH, accompanied by improvement in respiratory function. She transitioned from LMWH to apixaban two days before discharge. Overall, the favorable outcome of the modified intermediate LMWH regimen followed by maintenance apixaban in this case adds evidence to the balanced approach in the anticoagulation strategy for concurrent PE and ICH.