Ann Thorac Surg 2006;81:735-737
© 2006 The Society of Thoracic Surgeons
Case report
Rescue Surgical Embolectomy for Fatal Pulmonary Embolism in Patient With Intracranial Hemorrhage
Ikuo Fukuda, MD
a
,
b
,
*
,
Kozo Fukui, MD
a
,
Masahito Minakawa, MD
a
,
Masayuki Koyama, MD
a
,
Ikko Ichinoseki, MD
a
,
Yasuyuki Suzuki, MD
a
a Department of Surgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
b Department of Cardiovascular Surgery, Tsukuba Medical Center, Tsukuba, Ibaraki, Japan
Accepted for publication October 28, 2004.
* Address correspondence to Dr Fukuda, Department of Surgery, Hirosaki University School of Medicine, 5-Zaifucho, Hirosaki, Aomori, 036–8562 Japan (Email: ikuofuku{at}cc.hirosaki-u.ac.jp).
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Abstract
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The incidence of pulmonary embolism is relatively high in stroke patients due to prolonged bed rest, paralysis of the lower extremities, and dehydration. We herein report three cases of pulmonary embolectomy for patients with intracranial hemorrhage. All patients had massive central pulmonary embolism and were in deep shock. The interval between the onset of intracranial bleeding and surgical embolectomy was 7 to 16 days. All patients underwent emergent pulmonary embolectomy using cardiopulmonary bypass and survived without any neurologic exacerbation. Surgical pulmonary embolectomy is a treatment of choice to save patients with massive pulmonary embolism after intracranial hemorrhage.
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Introduction
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The incidence of pulmonary embolism is relatively high in stroke patients due to prolonged bed rest, paralysis of the lower extremities, and dehydration due to hyperosmolar therapy [1]. Pulmonary embolism is one of the major causes of death after stroke. This is a review of patients who underwent surgical embolectomy for management of pulmonary embolus complicating intracranial hemorrhage.
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Case Reports
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Patient 1
A 57-year-old woman was admitted as a patient due to cerebral contusion, subdural hematoma, and fracture of the pelvis and cervical spine caused by a traffic accident. Decompression and fixation of the cervical spine was performed on day 10 because of exacerbation of tetraparesis. On day 16, the patient suddenly exhibited circulatory collapse and stupor. Emergent pulmonary angiography revealed massive pulmonary embolism in bilateral main pulmonary arteries. Because the patient exhibited bradycardia and severe hypotension after angiography, the patient was transferred to the operating room for emergent pulmonary embolectomy. Extracorporeal circulation was instituted through the right femoral artery and vein, and pulmonary embolectomy was performed through a median sternotomy. The interval between onset and embolectomy was 7 hours, and the interval between definitive diagnosis and institution of cardiopulmonary bypass was 30 minutes. The patient's hemodynamics stabilized and no neurologic deficit remained. To prevent recurrence, continuous infusion of heparin sodium was given after the surgery. However, intracranial hemorrhage occurred on postoperative day 6. Infusion of the heparin was discontinued and interruption of the inferior vena cava was performed. The patient was discharged without any neurologic deficit.
Patient 2
A 63-year-old woman was admitted as a patient due to subarachnoid hemorrhage. Intracranial aneurysm could not be detected by repeat cerebral angiography. On day 7, the patient lost consciousness and went into shock. Echocardiography revealed right ventricular distension, left ventricular collapse, and tachycardia. Urgent pulmonary angiography revealed massive pulmonary thromboembolism in bilateral main pulmonary arteries. Although catheter directed fragmentation was attempted, the patient fell into deep shock, and exhibited bradycardia. Cardiac massage was begun, and the patient was transferred to the operating room immediately. Pulmonary embolectomy was successfully performed under cardiopulmonary bypass. Inferior vena cava filter was inserted after the operation. Anticoagulant therapy was not performed. The patient was discharged without any neurologic deficit.
Patient 3
The patient was a 67-year-old man who had right hemiplegia due to hypertensive intracranial hemorrhage (Fig 1). On day 8 after the onset of stroke, the patient went into circulatory collapse and lost consciousness in the rehabilitation room. Cardiopulmonary resuscitation was begun immediately, but the patient was still in deep shock. Enhanced computed tomographic scan of the chest revealed massive pulmonary emboli in the pulmonary trunk and bilateral main pulmonary arteries (Fig 2). The patient was transferred to our hospital 6 hours after the onset. Because fibrinolytic therapy was contraindicated, emergent pulmonary embolectomy and insertion of an inferior vena cava filter was carried out immediately (Fig 3). After the operation, hemodynamics of the patient became stable and the patient regained consciousness. Computed tomography of the brain revealed no exacerbation of intracranial hematoma. The patient was transferred to the rehabilitation home. His neurologic status improved to mild disability with right hemiparesis.
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Fig 1. Preoperative brain computed tomographic scan of patient 3. There was massive intracranial hematoma with a midline shift.
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Fig 2. Enhanced chest computed tomographic scan revealed saddle embolism from the pulmonary trunk into the bilateral main pulmonary arteries.
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Comment
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Acute massive pulmonary embolism is a life threatening disorder with a high mortality of 25% in patients with shock and 65% in those who have been resuscitated from cardiopulmonary arrest [2]. Although preventive procedures using low molecular weight heparin or elastic stocking were proven to be effective and safe for patients with intracranial hemorrhage, there are still "unexpected" sudden deaths due to massive pulmonary embolism [3]. Open pulmonary embolectomy has been abandoned in many institutes after the advent of fibrinolytic therapy in the 1970s. Fibrinolytic therapy is effective for pulmonary embolism with right ventricular overload [4]. However, fibrinolytic therapy is contraindicated in patients with intracranial hemorrhage or in patients after craniotomy because of high incidence of intracranial re-bleeding. Therefore, surgical pulmonary embolectomy is only used as a lifesaving treatment for such "fatal" pulmonary embolism to solve this therapeutic dilemma [5]. Although catheter-directed fragmentation of embolus or aspiration embolectomy is an alternative to surgical embolectomy, relief from pulmonary artery obstruction is uncertain and still remains an experimental procedure.
The concern for surgical embolectomy is exacerbation of intracranial bleeding due to systemic heparinization. Burden for heparinization depends on the duration of heparin administration as shown in patient 1. Pulmonary embolism occurs most commonly at the end of week 2 after a stroke. Short-term extracorporeal circulation and discontinuation of anticoagulant therapy after relief from right ventricular overload may be more advantageous than prolonged administration of anticoagulant agents in patients with intracranial bleeding. Insertion of a caval filter is also necessary to prevent recurrence of pulmonary embolism.
Although this is the experience of only a few patients, and uncertainty still remains critical in this situation, we believe surgical pulmonary embolectomy is the treatment of choice to save patients with massive pulmonary embolism after stroke.
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References
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- Oppenheimer S, Hachinski V. Complications of acute stroke Lancet 1992;339:721-724.[Medline]
- Kasper W, Konstantinides S, Geibel A, et al. Management strategies and determinants of outcome in acute major pulmonary embolismresults of a multicenter registry. J Am Coll Cardiol 1997;30:1165-1171.[Abstract]
- Kelly J, Hunt BJ, Lewis RR, Rudd A. Anticoagulation or inferior vena cava filter placement for patients with primary intracerebral hemorrhage developing venous thromboembolism? Stroke 2003;34:2999-3005.[Abstract/Free Full Text]
- UPET study group Urokinase-streptokinase embolism trialphase II results. JAMA 1974;2291601–13G.
- Yalamanchili K, Fleisher AG, Lehrman SG, et al. Open pulmonary embolectomy for treatment of major pulmonary embolism Ann Thorac Surg 2004;77:819-823.[Abstract/Free Full Text]
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