How should a patient with bilateral pulmonary embolism and multiple subdural hematomas after a prior burr‑hole be managed in the hospital?

Management of Bilateral PE with Multiple Subdural Hematomas Post-Burr Hole

This patient requires immediate anticoagulation with unfractionated heparin (UFH) via continuous IV infusion for the bilateral PE, while avoiding thrombolysis due to the absolute contraindication of recent intracranial bleeding, combined with early mechanical thromboprophylaxis and close neurosurgical monitoring for hematoma expansion. 1, 2

Immediate Anticoagulation Strategy

Start UFH immediately via continuous IV infusion rather than LMWH or fondaparinux, as UFH has a short half-life (60-90 minutes) that allows rapid reversal with protamine sulfate if intracranial bleeding worsens 2. This is critical given the competing risks of PE mortality versus subdural hematoma expansion.

• Administer UFH with an initial bolus of 5,000 units IV, followed by continuous infusion of 20,000-40,000 units/24 hours (approximately 1,000-1,500 units/hour for average adult) 2
• Monitor aPTT every 4 hours initially, targeting 1.5-3 times control value (typically 60-85 seconds) 2
• Check baseline and serial platelet counts, hematocrit, and coagulation parameters 2

Why Thrombolysis is Absolutely Contraindicated

Do not administer systemic thrombolysis despite bilateral PE, as recent neurosurgery (burr hole) and active intracranial bleeding represent absolute contraindications 1. The ESC guidelines explicitly list "recent brain or spinal surgery" and "structural intracranial cerebrovascular disease" as absolute contraindications to thrombolytic therapy 1.

• Major intracranial bleeding occurs in 1.9-3.0% of PE patients receiving thrombolysis under normal circumstances 1
• Your patient's risk would be exponentially higher given multiple subdural hematomas and recent burr hole surgery

Alternative Interventions if Hemodynamic Instability Develops

If the patient develops shock (SBP <90 mmHg) or persistent hypotension despite anticoagulation:

Consider surgical embolectomy or catheter-directed intervention as alternatives to thrombolysis 1. The ESC guidelines specifically recommend surgical embolectomy for high-risk PE when thrombolysis is contraindicated or has failed 1.

• Surgical embolectomy via normothermic cardiopulmonary bypass has perioperative mortality rates of 6% or less in experienced centers 1
• Pre-operative thrombolysis increases bleeding risk but is not an absolute contraindication to surgical embolectomy—however, your patient hasn't received thrombolysis, making surgery safer 1
• Catheter-directed mechanical thrombectomy (fragmentation, rheolytic, or suction thrombectomy) achieves 87% clinical success without systemic thrombolysis 1

Mechanical Thromboprophylaxis Protocol

Initiate intermittent pneumatic compression (IPC) immediately while the patient has active bleeding risk from subdural hematomas 1. This provides VTE prophylaxis without increasing intracranial bleeding risk.

• Do NOT use graduated compression stockings—they lack evidence of benefit and may cause harm 1
• Continue IPC until subdural hematomas are stable and full anticoagulation is safely established 1

Neurosurgical Monitoring Requirements

Obtain urgent neurosurgical consultation and serial neuroimaging to monitor for subdural hematoma expansion while on anticoagulation 3, 4.

• Perform baseline CT head immediately, then repeat at 24 hours and 72 hours, or sooner if neurological deterioration occurs 3
• Monitor for signs of increased intracranial pressure: declining GCS, new focal deficits, headache worsening, or pupillary changes 3
• Bilateral subdural hematomas have a 28% recurrence rate (versus 9.59% for unilateral), requiring heightened vigilance 3
• Keep protamine sulfate immediately available at bedside for UFH reversal if intracranial bleeding worsens 2

Critical Decision Point: When to Reverse Anticoagulation

Immediately reverse UFH with protamine sulfate (1mg per 100 units of heparin given in last 2-3 hours) if any of the following occur 2:

• Decline in GCS by ≥2 points
• New or worsening focal neurological deficits
• CT evidence of subdural hematoma expansion >5mm or new midline shift
• Signs of herniation (pupillary asymmetry, posturing, Cushing's triad)

Transition to Long-Term Anticoagulation

Once subdural hematomas are radiologically stable (typically 7-14 days post-burr hole):

Transition from UFH to a NOAC (rivaroxaban or apixaban preferred) rather than continuing UFH or switching to LMWH 5. NOACs have lower intracranial bleeding rates than warfarin and don't require INR monitoring 5.

• Wait minimum 7-10 days with stable repeat CT scans before transitioning 3, 6
• Rivaroxaban 15mg BID for 21 days, then 20mg daily, or apixaban 10mg BID for 7 days, then 5mg BID 5
• Continue anticoagulation indefinitely if PE was unprovoked (annual recurrence risk >5%) 5

Avoid These Common Pitfalls

• Do not place an IVC filter—filters don't reduce mortality and increase complication risk, even in patients with anticoagulation contraindications 5
• Do not use LMWH initially—its longer half-life (4-6 hours) and lack of complete reversibility make it dangerous in this setting with active intracranial pathology 2
• Do not delay anticoagulation waiting for "perfect" conditions—bilateral PE carries 15-30% mortality risk untreated, requiring immediate action with close monitoring 1
• Do not restart antiplatelet agents if patient was on them pre-operatively until subdural hematomas completely resolve (typically 4-6 weeks minimum) 1

Mandatory Follow-Up

Schedule outpatient reassessment at 3-6 months post-PE to screen for chronic thromboembolic pulmonary hypertension (CTEPH) and determine ongoing anticoagulation duration 5. Perform V/Q scan if patient remains symptomatic with dyspnea 5.