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Systemic Thrombolysis in a Patient with Massive Pulmonary Embolism and Recent Glioblastoma Multiforme Resection

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Systemic Thrombolysis in a Patient with Massive Pulmonary Embolism and Recent Glioblastoma Multiforme Resection Unusual presentation of more common disease/injury BMJ Case Reports: first published as 10.1136/bcr-2017-221578 on 29 November 2017. Downloaded from CASE REPORT Systemic thrombolysis in a patient with massive pulmonary embolism and recent glioblastoma multiforme resection Joshua Lampert,1 Behnood Bikdeli,2 Philip Green,3 Matthew R Baldwin4 1Department of Internal SUMMARY and 2013 American College of Cardiology Foun- Medicine, Columbia University While trials of systemic thrombolysis for submassive and dation/AHA Task Force on Practice Guidelines list Medical Center, New York City, massive pulmonary embolism (PE) report intracranial known malignant intracranial neoplasm and brain New York, USA haemorrhage (ICH) rates of 2%–3%, the risk of ICH or spinal canal surgery within 2 months as absolute 2Division of Cardiology, in patients with recent brain surgery or intracranial contraindications to thrombolysis for treatment Columbia University Medical 8 9 Center, New York, NY neoplasm is unknown since these patients were of PE and ST-elevation myocardial infarction. 3Division of Cardiology, excluded from these trials. We report a case of massive The Neurocritical Care Society does not provide Columbia University Medical PE treated with systemic thrombolysis in a patient with guidelines for treatment of venous thromboembo- Center, New York, NY recent neurosurgery for an intracranial neoplasm. We lism (VTE). While the ACCP guidelines note that 4Division of Pulmonary discuss the risks and benefits of systemic thrombolysis the more severe the hypotension, the more compel- and Critical Care Medicine, for massive PE in the context of previous case reports, ling the indication for systemic thrombolysis, there Columbia University College of prior cohort studies and trials, and current guidelines. are no specific recommendations to guide weighing Physicians and Surgeons, New There may be times when the immediate risk of death the risks of ICH versus worsening circulatory shock York, NY from massive PE outweighs the risk of ICH from in patients with massive PE and these major contra- systemic thrombolysis, even when guideline-listed Correspondence to indications to thrombolysis. This is likely due to Dr Joshua Lampert, major contraindications exist. This case provides an the fact that the risk of ICH in patients with these jml9026@ nyp. org example of how the haemodynamic benefit of systemic contraindications is unknown since they have tradi- thrombolysis outweighed the impact of ICH in a patient tionally been excluded from thrombolysis trials for Accepted 10 November 2017 who had undergone recent neurosurgical resection of a acute PE and myocardial infarction.5 10 11 glioblastoma multiforme tumour. CASE PRESENTATION A 54-year-old woman presented to the emergency department with acute-onset pleuritic chest pain BACKGROUND http://casereports.bmj.com/ Massive pulmonary embolism (PE) is defined by for 2 days and a tight sensation in her left calf. One systemic arterial hypotension and cardiogenic shock month prior to presentation, she underwent neuro- from right ventricular failure due to an obstruc- surgical resection of a right frontal lobe glioblas- tive embolism. Systemic arterial hypotension is toma multiforme (GBM), and had postoperative defined as a systolic arterial pressure <90 mm left-sided hemiparesis. She had been discharged Hg or a drop in systolic pressure >40 mm Hg to a subacute rehabilitation facility where she did for >15 min. Shock is defined by tissue hypoperfu- not receive VTE prophylaxis. At presentation, she sion, presenting as hypoxia, altered mental status, was tachycardic (110 beats/min), normotensive 1 (118/60 mm Hg), tachypnoeic (26 breaths/min) and oliguria or cool extremities. In-hospital mortality in patients with massive PE ranges from 15% for hypoxaemic (peripheral capillary oxygen saturation on 3 October 2021 by guest. Protected copyright. those with arterial hypotension to 65% for those (SpO2) of 90% while breathing ambient air). The with cardiac arrest.2 In two separate meta-anal- ECG showed sinus tachycardia and serum cardiac yses of randomised controlled trials that included troponin-T was 0.1 ng/mL (upper limit of normal patients with massive PE, systemic thrombolysis 0.01 ng/mL). CT pulmonary angiography (CTPA) reduced the risk of in-hospital death by approxi- showed large emboli in the right pulmonary artery mately 50%.3 4 However, this mortality benefit is and the right segmental and subsegmental branches offset by major bleeding in approximately 10% of with additional small emboli in the left segmental patients, with 2%–3% having intracranial haem- pulmonary artery branches (figure 1A). She was orrhage (ICH).5 6 The 2016 American College of started on anticoagulation for acute PE with an Chest Physicians (ACCP) Guidelines and Expert 80 units/kg intravenous bolus of unfractionated Panel Report for Antithrombotic Therapy for VTE heparin followed by an 18 units/kg/hour infusion, Disease lists structural intracranial disease, recent and was admitted to the hospital intermediate care T Lampert J,o cite: Bikdeli B, brain surgery, prior ICH and ischaemic stroke unit. Green P, et al. BMJ Case Rep Published Online First: within 3 months as major contraindications for Eight hours later, she acutely developed hypo- [please include Day Month thrombolytic therapy due to an increased risk of tension to 50/30 mm Hg and worse hypoxaemia Year]. doi:10.1136/bcr-2017- 7 ICH with systemic thrombolysis. The 2011 Amer- (SpO2 70% on supplemental oxygen at 15 L/min 221578 ican Heart Association (AHA) Scientific Statement delivered through a non-rebreather facemask). Her Lampert J, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221578 1 Unusual presentation of more common disease/injury BMJ Case Reports: first published as 10.1136/bcr-2017-221578 on 29 November 2017. Downloaded from Figure 1 CT pulmonary angiography (CTPA) demonstrating pulmonary embolism (PE). (A) CTPA prior to thrombolysis demonstrating large right main pulmonary embolus extending into the segmental branches (red arrow). (B) CTPA demonstrating resolution of pulmonary emboli 4 days after thrombolysis. ECG showed new ST elevation in aVR and V1, and ST depres- sions in I, aVL and V5–V6. Bedside echocardiography revealed a markedly dilated, severely hypokinetic right ventricle with apical sparing, interventricular septal bowing into the left ventricle, and a single thrombus moving between the right atrium and the right ventricle (figure 2A–C). Norepinephrine infusion was started at 5 mcg/min and rapidly titrated to 40 mcg/min, the maximum Figure 3 CT of head demonstrating haemorrhage into resection dose permitted at our institution. She remained in refractory site. (A) Intracranial haemorrhage into resection cavity (red arrow) circulatory shock with a blood pressure of 85/60 mm Hg. 3 hours after thrombolysis. (B) Evolution of haemorrhage stable on After consulting with specialists from cardiothoracic surgery, follow-up without neurosurgical intervention 3 days after intracranial pulmonary critical care, interventional cardiology and neuro- haemorrhage was diagnosed. (C) Follow-up CT 6 months after discharge surgery, we administered 10 mg of alteplase, tissue plasminogen demonstrating glioblastoma multiforme (GBM) progression (red arrow) activator (t-PA), intravenously over 1 min followed by a 90 mg and midline shift (green line) with resolution of haemorrhage. infusion over 2 hours and transferred the patient to the intensive care unit. Within 3 hours, her circulatory shock resolved, norepi- nephrine was weaned off, and her SpO2 improved to 98% on nasal cannula at 2 L/min. A head CT obtained 3 hours after t-PA http://casereports.bmj.com/ initiation revealed an acute 3×1.4 cm right frontal lobe haem- orrhage within the resection cavity with a 4 mm midline shift (figure 3A) (a postoperative head CT from 1 month prior had a 3 mm midline shift). Unfractionated heparin infusion was discontinued upon initi- ating t-PA and was not resumed due to acute ICH. An inferior vena cava (IVC) filter was placed after a distal left popliteal occlu- sive thrombus was visualised by ultrasonography with Doppler. Repeat head CT after 3 days showed no further ICH nor midline shift (figure 3B). She did not develop any new neurological defi- on 3 October 2021 by guest. Protected copyright. cits at any time. One day after thrombolysis, echocardiography demonstrated normal right ventricular function and no evidence of intracardiac thrombus. Four days later, CTPA showed near complete resolution of the large pulmonary emboli with residual small emboli in the right upper and left lower lobar arteries (figure 1B). She was discharged to a postacute care facility 6 days later without a need for supplemental oxygen. The IVC filter was left in situ. Two weeks later, a head CT showed resolution of the haemorrhage, and she was started on therapeutic enoxaparin at 1 mg/kg subcutaneously every 12 hours. Medical history: GBM complicated by left hemiparesis and Figure 2 Transthoracic echocardiogram (apical four-chamber seizures status post-tumour resection 1 month prior to presenta- view). (A) Thrombus in right atrium (red arrow). (B) Thrombus in right tion, obesity, hypertension, left breast cyst removal and vaginal atrium superior to tricuspid valve. (C) Thrombus in right ventricle; cyst removal. IVS bowing intoleft ventricle. Red arrows denote thrombus. IVS, Social history: Since being discharged from the hospital after interventricular septum; LA, left atrium; LV, left ventricle; RA, right brain surgery, she resided at a rehabilitation facility learning how atrium; RV, right ventricle. to cope with her left hemiparesis and basic activity of daily living 2 Lampert J, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221578 Unusual presentation of more common disease/injury BMJ Case Reports: first published as 10.1136/bcr-2017-221578 on 29 November 2017. Downloaded from dependence. She is unemployed and has a 42 pack-year smoking 6–24 mm had a 2.7 and 13.5 greater odds of 30-day mortality history without any illicit drug or supplement use. compared with patients with ICH without midline shift, respec- Family history: There is no significant family history.
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