Lee Wei-Chieh, Fang Hsiu-Yu
Division of Cardiology, Department of Internal Medicine Division of Cardiology, Cardiac Care Unit, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China.
Medicine (Baltimore). 2018 Apr;97(15):e0479. doi: 10.1097/MD.0000000000010479.
Venous thromboembolism may result from prolong immobilization following intracerebral hemorrhage. Massive pulmonary embolism with associated right heart failure is life-threatening, requiring treatment with anticoagulants or even thrombolytic agents. However, these drugs are contraindicated after a recent hemorrhagic episode, as they may induce further hemorrhage. There are no guidelines for treatment in these circumstances.
A 57-year-old man experienced massive pulmonary embolism and shock 18 days after an intracerebral hemorrhage.
Tachycardia and high D-dimer (21.27 mg/L fibrinogen-equivalent units) were noted. Chest computed tomography showed bilateral pulmonary trunk embolism.
Heparinization were used and activated partial thromboplastin time therapeutic range was 50 to 70 seconds. Fortunately, shock status and shortness of breath improved two days later. Continuing high dose Rivaroxaban was administrated for three weeks.
There was no recurrent intracranial hemorrhage (ICH) following treatment for three-weeks with high-dose and one-year with standard dose of rivaroxaban. This report presents a treatment option in the management of these difficult clinical situations.
The combination of unfractionated heparin infusion and continuing non-Vitamin K antagonist oral anticoagulants use could manage life-threatening pulmonary embolism following recent ICH. Theoretically, the use of NOAC is a safer strategy if the patient with previous history of major ICH.
脑出血后长期制动可能导致静脉血栓栓塞。大面积肺栓塞伴右心衰竭危及生命，需要使用抗凝剂甚至溶栓药物治疗。然而，近期有出血发作后这些药物是禁忌的，因为它们可能导致进一步出血。在这些情况下没有治疗指南。
一名57岁男性在脑出血后18天发生大面积肺栓塞并休克。
发现心动过速和高D-二聚体（21.27mg/L纤维蛋白原当量单位）。胸部计算机断层扫描显示双侧肺动脉主干栓塞。
采用肝素化，活化部分凝血活酶时间治疗范围为50至70秒。幸运的是，两天后休克状态和呼吸急促有所改善。继续给予高剂量利伐沙班治疗三周。
高剂量利伐沙班治疗三周和标准剂量治疗一年后均未发生复发性颅内出血（ICH）。本报告提出了在这些困难临床情况下的一种治疗选择。
普通肝素输注与持续使用非维生素K拮抗剂口服抗凝剂相结合可治疗近期脑出血后危及生命的肺栓塞。理论上，如果患者有既往重大ICH病史，使用新型口服抗凝药是一种更安全的策略。
