How should I manage a patient with bilateral pulmonary embolism and multiple subdural hematomas after burr‑hole drainage?

Management of Bilateral Pulmonary Embolism with Multiple Subdural Hematomas After Burr-Hole Surgery

Start unfractionated heparin (UFH) by continuous intravenous infusion immediately, because recent neurosurgery and active subdural hematomas constitute absolute contraindications to systemic thrombolysis, and untreated bilateral PE carries 15–30% mortality that mandates prompt anticoagulation despite the intracranial bleeding risk. 1

Immediate Anticoagulation Strategy

• Initiate UFH continuous IV infusion without delay at 18 units/kg/hour (approximately 1,250–1,500 units/hour for a 70 kg patient) after a 75–80 units/kg bolus, targeting aPTT of 1.5–2.5 times control (approximately 60–85 seconds). 1, 2

• UFH is the only acceptable anticoagulant in this scenario because its 60–90 minute half-life permits rapid reversal with protamine sulfate (1 mg per 100 units of heparin given in the preceding 2–3 hours) if intracranial bleeding worsens. 1, 2

• Do not use low-molecular-weight heparin (LMWH) despite its convenience, because its 4–6 hour half-life and incomplete reversibility create unacceptable bleeding risk with active intracranial pathology. 1

• Monitor aPTT every 4 hours initially, then at appropriate intervals once therapeutic range is achieved; check platelet count, hematocrit, and perform neurological assessments every 4–6 hours. 2

Absolute Contraindications to Thrombolysis

• Systemic thrombolysis is absolutely prohibited in this patient because ESC guidelines list "recent brain or spinal surgery" and "structural intracranial cerebrovascular disease" as prohibitive contraindications. 1, 3

• The risk of major intracranial hemorrhage with thrombolysis in ordinary PE patients is 1.9–3.0%; this risk becomes markedly higher after recent neurosurgery and with existing subdural hematomas. 1

Rescue Reperfusion if Hemodynamic Deterioration Occurs

If the patient develops shock (systolic BP <90 mmHg for >15 minutes) or persistent hypotension despite UFH:

• Surgical pulmonary embolectomy is the preferred rescue intervention when thrombolysis is contraindicated, with perioperative mortality ≤6% in experienced centers using normothermic cardiopulmonary bypass. 1, 3

• Catheter-directed mechanical thrombectomy (fragmentation, rheolytic, or suction devices) achieves approximately 87% clinical success without systemic thrombolysis and represents a viable alternative if surgical expertise is unavailable. 1, 3, 4

• Activate your institution's Pulmonary Embolism Response Team (PERT) immediately to coordinate multidisciplinary decision-making between neurosurgery, cardiac surgery, interventional cardiology, and critical care. 4

Mechanical VTE Prophylaxis

• Begin intermittent pneumatic compression (IPC) on both lower extremities immediately to provide ongoing VTE prophylaxis while the patient remains at high bleeding risk; IPC does not increase hemorrhagic complications. 1

• Continue IPC until serial CT imaging (at 48–72 hours, then 5–7 days) confirms stability of the subdural hematomas and therapeutic anticoagulation can be safely maintained. 1

• Avoid graduated compression stockings, as evidence shows no benefit and potential harm in acute PE. 1

Criteria for Immediate UFH Reversal

Reverse UFH with protamine sulfate immediately if any of the following occur:

• Glasgow Coma Scale decline ≥2 points from baseline. 1
• Clinical signs of brain herniation: pupillary asymmetry, decorticate/decerebrate posturing, or Cushing's triad (bradycardia, hypertension, irregular respirations). 1
• New or expanding hematoma on urgent CT imaging. 1

After reversal, obtain urgent neurosurgical consultation and repeat head CT; if the subdural hematomas are stable, cautiously restart UFH at a lower infusion rate (10–12 units/kg/hour) after 6–12 hours. 1

Transition to Long-Term Anticoagulation

• After radiologic stability of the subdural hematomas (generally 7–14 days post-burr-hole, confirmed by repeat CT showing no expansion), transition from UFH to a direct oral anticoagulant (NOAC). 1, 3

• Prefer apixaban or rivaroxaban over warfarin because NOACs are associated with 50–60% lower rates of intracranial bleeding compared with warfarin and do not require INR monitoring. 1, 3, 5

• For apixaban: 10 mg twice daily for 7 days, then 5 mg twice daily; for rivaroxaban: 15 mg twice daily for 21 days, then 20 mg once daily. 3, 5

• Continue anticoagulation indefinitely for this unprovoked PE (annual recurrence risk >5% without ongoing treatment). 1, 5

Critical Pitfalls to Avoid

• Do not place an inferior vena cava (IVC) filter; meta-analyses show no mortality benefit even when anticoagulation is temporarily contraindicated, and filters increase long-term complication rates. 1, 5

• Do not delay UFH initiation while awaiting "perfect" conditions or complete resolution of the subdural hematomas; the mortality risk of untreated bilateral PE far exceeds the bleeding risk of carefully monitored UFH. 1

• Do not restart any pre-operative antiplatelet agents (aspirin, clopidogrel) until the subdural hematomas have fully resolved on imaging, typically 4–6 weeks post-burr-hole. 1

• Do not use NOACs during the acute phase while subdural hematomas remain unstable; their longer half-lives (8–15 hours) and lack of specific reversal agents (except for dabigatran) make them unsuitable until intracranial pathology has stabilized. 1, 5

Mandatory Follow-Up Protocol

• Re-evaluate at 3–6 months after the acute PE episode to screen for chronic thromboembolic pulmonary hypertension (CTEPH), assess ongoing anticoagulation needs, and confirm resolution of subdural hematomas. 3, 5

• If the patient reports persistent dyspnea or functional limitation at follow-up, obtain a ventilation-perfusion (V/Q) scan to assess for residual perfusion defects suggestive of CTEPH. 1, 5

• Arrange annual follow-up visits to monitor for VTE recurrence, bleeding complications, and any late neurological sequelae from the subdural hematomas. 3, 5