What question did this study set out to answer?

To explore the management of pulmonary embolism in a patient with concurrent intracranial hemorrhage.

February 26, 2026Open Access

Therapeutic Challenge in a Case of Extensive Pulmonary Embolism with Concomitant Intracranial Haemorrhage: When Less is Really More

Key Points

To explore the management of pulmonary embolism in a patient with concurrent intracranial hemorrhage.
Analyzed a case of a 50-year-old woman with left basal ganglia hemorrhage and pulmonary embolism.
Managed ICH conservatively while monitoring for respiratory complications.
Employed intermediate dose low molecular weight heparin as empirical treatment.
Confirmed diagnosis with CT pulmonary angiogram and monitored outcomes via serial brain CT.
CTPA confirmed extensive pulmonary embolism with pulmonary infarction.
D-dimer levels elevated, indicating clot formation.
Steady resolution of intracranial hemorrhage observed in serial CT scans.
Patient improved respiratory function and transitioned to apixaban before discharge.

Abstract

Abstract: Pulmonary embolism is a conundrum that clinicians often need to grapple with when managing patients with recent intracranial hemorrhage (ICH). A 50-year-old woman was admitted to the medical ward for left basal ganglia hemorrhage caused by a hypertensive emergency with resultant dense right hemiparesis. The ICH was managed conservatively by neurosurgical team. On day 9 of admission, the patient developed acute respiratory distress that required high-flow nasal cannula support. Her D-dimer level was increased with bedside ultrasonography revealing right heart strain patterns that warranted empirical pulmonary embolism (PE) treatment. Balancing the risk of ICH expansion and imminent respiratory collapse, she was empirically treated with intermediate dose low molecular weight heparin (LMWH) while awaiting CT pulmonary angiogram (CTPA) examination. CTPA confirmed the diagnosis of extensive PE with right lower lobe pulmonary infarction. Subsequent serial brain CT showed steady resolution of the ICH, accompanied by improvement in respiratory function. She transitioned from LMWH to apixaban two days before discharge. Overall, the favorable outcome of the modified intermediate LMWH regimen followed by maintenance apixaban in this case adds evidence to the balanced approach in the anticoagulation strategy for concurrent PE and ICH. Keywords: anticoagulation, apixaban, intracranial haemorrhage, low molecular weight heparin, pulmonary embolism

Bookmark

View Full Paper