Category: Clinical Sciences/Health Conditions
Case Diagnosis: Saddle Pulmonary Embolism, Hemorrhagic Stroke
Case Description: A 56 year-old male with history of hypertension was admitted to acute inpatient rehabilitation (AIR) after an acute right pontine hemorrhagic stroke attributed to uncontrolled hypertension. He was continued on Heparin 5,000 units q12hrs for venous thromboembolism prophylaxis on AIR Day 1. He was functionally progressing well in all therapy sessions until AIR Day 15 when he reported new-onset shortness of breath during physical therapy. Initial SpO2 was 85% on room air in the therapy gym. Repeat SpO2 was 95% on 4L O2 nasal cannula. He was tachycardic (110 bpm) and normotensive (104/84 mmHg). He was immediately transferred to an acute care hospital ED and CTA chest revealed acute bilateral pulmonary emboli (PE) including a saddle pulmonary embolus.
Discussions: The patient was started on a heparin drip and eventually underwent IVC filter placement. He was transitioned to Coumadin prior to being transferred back to AIR, where he completed his rehabilitation without complications. He was discharged home independent on all ADLs and modified independent for ambulation after a two-week AIR stay.
The incidence of PE in post-stroke patients is less than 1%, with a higher rate of PE in hemorrhagic strokes compared to ischemic strokes. However, PE has a high mortality rate in post-stroke patients (up to 25%). Currently, there are no definitive guidelines on the management of acute PE in hemorrhagic stroke patients due to the high risk of rebleeding. This case sheds light on one of the few management options for PE in hemorrhagic stroke patients.
Conclusions: Development of PE is possible in patients with hemorrhagic strokes despite receiving VTE chemoprophylaxis. This life-threatening condition should always be considered in patients presenting with acute-onset shortness of breath during inpatient rehabilitation. Early recognition of PE is crucial for appropriate intervention, leading to favorable functional outcomes for the patient.
Kevin Machino– Resident Physician, Schwab Rehabilitation Hospital