Skip Navigation
Skip to contents

ACC : Acute and Critical Care

OPEN ACCESS
SEARCH
Search
Advanced Search
mobile menu button

Articles

Page Path
HOME > Acute Crit Care > Volume 41(2); 2026 > Article
Original Article
Cardiology Managing symptomatic intermediate or high-risk pulmonary embolism presenting concomitantly with intracranial bleeding: case series and literature review
Acute and Critical Care 2026;41(2):344-355.
DOI: https://doi.org/10.4266/acc.001075
Published online: March 4, 2026

1Asian Heart and Vascular Centre, Singapore

2International Neuro Associates, Singapore

3National University Heart Centre, Singapore

4The Heart Clinic, Singapore

Corresponding author: Pipin Kojodjojo Asian Heart and Vascular Centre, 3 Mount Elizabeth, #10-14, Singapore 228510 Tel: +65-6911-0066 Email: drko_pipin@ahvc.com.sg
• Received: March 31, 2025   • Revised: July 17, 2025   • Accepted: November 14, 2025

© 2026 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • 1,971 Views
  • 25 Download
prev next
Full Article

Download PDF Download PDF

  • Background
    Managing patients with concomitant intracranial bleeding (ICB) and symptomatic pulmonary embolism (PE) is challenging and there are no guidelines.
  • Methods
    We identified patients with intermediate or high-risk PE and concomitant ICB referred to our institutional PE response teams. A literature review was performed to evaluate the effectiveness and risks of various treatment strategies for this challenging clinical conundrum.
  • Results
    Two patients with subdural hematoma, symptomatic intermediate-high risk PE and deep vein thrombi were identified in our institutions. Both patients were treated with lytic-free mechanical thrombectomy combined with inferior vena cava (IVC) filter implantation. This allowed for an anticoagulation-free period, during which surgical drainage was performed. Anticoagulation was safely started several days after neurosurgery. A literature review identified 148 similar cases. There was significant risk of in-hospital mortality due to PE in patients who were left untreated. Early anticoagulation was associated with elevated risks of hematoma expansion, extracranial bleeding and residual risk of PE mortality. Patients undergoing surgical or lytic-free mechanical thrombectomy all survived to discharge without bleeding complications.
  • Conclusions
    Combining thrombolytic-free mechanical thrombectomy with an IVC filter allows for effective PE treatment and temporary avoidance of anticoagulation whilst patients undergo definitive neurosurgery for concomitant ICB. Such an approach seems safer, less invasive and more clinically effective compared to other strategies reported in the literature.
  • Key Words: catheter thrombectomy; intracranial bleeding; pulmonary emboli; subdural hematoma; venous thromboembolism
Venous thromboembolism (VTE) is a common complication in patients with major trauma. According to the U.S. National Trauma Data Bank, out of 450,375 patients admitted to 131 trauma centers between 1994 and 2001, 604 (0.13%) patients were diagnosed with pulmonary embolism (PE). The mortality among these patients with PE was 18.7% [1]. Amongst a subset of trauma patients with subdural hematoma (SDH), Glasgow Coma Scale score of 8 or below and had undergone neurosurgery within 4 hours of hospital arrival, 13 out of 1,032 (1.3%) developed PE postoperatively [2]. Similarly, the risk of PE is approximately 36% more likely after spontaneous hemorrhagic stroke compared to acute ischemic stroke [3]. Up to 9% of deaths in the first 30 days after hemorrhagic strokes were due to PE [4]. Thus traumatic and non-traumatic intracranial bleeding (ICB) portends an increased risk of PE.
The management of patients with concomitant ICB and symptomatic PE is challenging and there are no guidelines. In these patients, the decision to treat the VTE involves balancing the risk of VTE progression against worsening ICB. Whilst many studies have examined the safety and efficacy of VTE prophylaxis in ICB patients, limited data exist about early, active treatment of these symptomatic VTE events, in particular PE. In a single centre series of 105 patients with traumatic ICB who received anticoagulation during the same admission, 32 patients had PE [5]. Anticoagulation in the form of heparin or warfarin was commenced a median of 6 days after a stable CT scan or neurosurgery. Three major bleeding complications (3%) occurred which did not require repeat surgery. Not treating the PE by withholding anticoagulation is associated with an estimated case fatality rate of 20% to 30% [6]. The availability of catheter thrombectomy tools especially those that do not require the use of thrombolytics provides a new treatment paradigm to manage such challenging patients [7,8].
In the present study, we identified patients with symptomatic, intermediate or high-risk PE and concomitant ICB being treated by our pulmonary embolism response teams (PERTs). A review of the literature was also performed to better evaluate the benefits and risks of therapies given to such challenging cases.
This study was performed according to the Helsinki Declaration and approved by the Institutional Review Board of National Healthcare Group (No. 2023/00976). Written informed consent was obtained from all patients.
Case Identification
Since 2021, patients with intermediate or high-risk PE at National University Heart Centre, Mt Elizabeth and Gleneagles Hospitals can be referred to a PERT, whereby consensus decision making is used to individualize the optimal management strategy. Treatment options available at all these hospitals consist of pharmacological therapy, systemic or catheter-directed thrombolysis, mechanical thrombectomy without the need for lytics, surgical embolectomy and extracorporeal membrane oxygenation (ECMO). The PERT team is accessible 24 hours, 7 days a week to all hospital colleagues and its core members consist of cardiologists accredited to perform catheter-based PE therapies and cardiac surgeons who can perform ECMO or surgical embolectomy. The admitting physician and specialists actively managing the patient’s comorbidities (in these cases neurologists and neurosurgeons) are also involved in the multi-disciplinary PERT discussions. Institutional protocols recommend that all intermediate- and high- risk PE patients, for active management, are referred to the PERT for evaluation. During each discussion, PE severity, symptom profile, hemodynamic status, patient’s comorbidities, risk of bleeding, patient wishes, etc. are evaluated to identify the optimal PE management strategy. The admitting physician and PE interventionalist would inform the patient and their caregivers about the consensus decision and obtain informed consent if the patient is agreeable to the proposed interventions. All patients referred to the PERT are prospectively enrolled into a registry. PE patients presenting simultaneously with ICB were identified in this post-hoc analysis.
Literature Review
A literature review was performed on the PubMed database, utilizing Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The first query used the following keywords intracranial hemorrhage, ICB, intracranial hematoma, subdural hematoma, subdural hemorrhage, subdural bleeding, intracerebral bleeding, subarachnoid bleeding, subarachnoid hematoma and subarachnoid hemorrhage, yielding a total of 166,767 articles. The first query was combined with the keyword “pulmonary emboli,” which produced 1,752 publications from database inception to 30 December 2024 (Figure 1). These publications were screened by title and abstract; and selected if they described the management and outcomes of patients with symptomatic PE and concomitantly any form of ICB. Exclusion criteria were reports written in a non-English language and those describing patients with: (1) deep vein thrombi (DVT) only or not distinction made between patients with PE and DVT; (2) remote history of ICB that has resolved or occurred more than 2 months ago; (3) at risk of but had yet to develop VTE; (4) intracranial tumors or cerebral infarcts without bleeding; and (5) ICB due to complications of anticoagulation or thrombolysis; indicated for treatment of VTE
Out of 182 patients enrolled in our prospective PERT registry between November 2021 and December 2024, two patients with intermediate-high risk PE and ICB were identified.
Patient 1
A 71 year-old man presented to the emergency department with sudden onset dyspnea whilst undergoing outpatient rehabilitation. He fell 2 weeks ago and developed a traumatic SDH which was treated conservatively (Figure 2). His past medical history includes hyperlipidemia and percutaneous coronary intervention 1 year ago. His regular medication included clopidogrel.
On arrival, blood pressure (BP) was 105/70 mm Hg, heart rate (HR) 90 bpm, respiratory rate of 24 per minute and oxygen saturation of 76% which improved to 95% with face mask and high flow oxygen. Arterial blood gas revealed a pH of 7.45, PCO2 of 34 mm Hg, PO2 of 42 mm Hg (FiO2 0.21, PO2/FiO2 or PaO₂/FiO₂ ratio 200), bicarbonate of 23 mmol/L and oxygen saturation of 81%. Both troponin I (232 ng/L) and NT-pro brain natriuretic peptide (BNP) (147 pg/mL) were elevated. Computed tomography pulmonary angiography (CTPA) showed extensive bilateral PE with right heart strain, confirmed by bedside echocardiography (Figure 3). Bilateral below-knee DVT were diagnosed on ultrasonography.
In considering anticoagulation, CT brain showed enlargement of the right SDH, with worsening mass effect and contralateral midline shift, compared to his last scan 2 weeks ago. The neurosurgical team was consulted, and systemic thrombolysis was deemed to be absolutely contraindicated. Anticoagulation alone would carry a high risk of worsening his ICB. The PERT was activated, and patient consented to the proposed management plan of percutaneous pulmonary thrombectomy without the use of thrombolytics and concomitant implantation of an inferior vena cava (IVC) filter.
Under local anesthesia and minimal conscious sedation, right common femoral vein access was obtained and large bore suction thrombectomy was performed (FlowTriever T24, Inari Medical) to both pulmonary arteries. Only 2,000 units of heparin was given to prevent equipment-related thrombus. Significant quantities of clot were aspirated (Figure 4). Contrast angiography confirmed significant reduction in clot burden but more importantly, improvement in mean pulmonary arterial pressures (46 to 25 mm Hg), HR, oxygen requirements (only 2 L post-procedure) and respiratory rates. A retrievable IVC filter (Celect Platinum, Cook Medical) was deployed in the infrarenal IVC. Repeat echocardiography confirmed normalization of right ventricular strain and size the next day. Over the next 7 days, the patient was not given any anticoagulation. Serial CT scans were stable but he elected to undergo burr hole drainage of the right SDH to expedite his recovery 7 days after pulmonary thrombectomy. Fourteen days after thrombectomy, he was started on 20 mg rivaroxaban and discharged home 2 days later. Three months after discharge, oral anticoagulant therapy was replaced with clopidogrel and he underwent elective removal of his IVC filter.
Patient 2
A 70 year-old male had a mechanical fall with head injury 6 weeks ago and developed frequent headaches. Separately, he noticed worsening dyspnea on exertion about 4 weeks before presentation. He has well-controlled hyperlipidemia, non-obstructive coronary artery disease on clopidogrel and benign prostatic hypertrophy. BP was 122/67 mm Hg, HR of 66 beats per minute and oxygen saturation of 91% on 2 L per minute oxygen. Physical examination was normal. Blood testing revealed elevated BNP levels of 400 pg/ml. Cerebral MRI demonstrated bilateral SDH which was larger on the right and a healing right frontal contusion (Figure 5). CTPA showed bilateral PE with right heart dilatation (right ventricular to left ventricular ratio >1) and unobstructed coronary arteries (Figure 6). These findings prompted immediate hospitalization and activation of the PERT within an hour of his CTPA. Right heart strain was confirmed on echocardiography with an estimated PASP of 45 mm Hg. There were bilateral below knee DVT on ultrasonography. Treatment options were discussed which included conservative therapy for both his SDH and PE; anticoagulation for 3 months with the hope that the SDH does not expand and deferred neurosurgery if he remained symptomatic; or to proceed with percutaneous pulmonary thrombectomy, concomitant IVC filter implantation followed by neurosurgery a few days later. He consented to the third option. On the day of admission, he underwent bilateral percutaneous pulmonary thrombectomy under local anesthesia with all visible clot aspirated which resulted in a fall in pulmonary arterial systolic pressure (PASP) from 40 mm Hg to 31 mm Hg and no further need for oxygen to maintain saturations above 97% post-procedurally (Figure 7). An IVC filter was implanted concomitantly via the same femoral access (Figure 8). Only 2,000 units of intraprocedural heparin was given to prevent catheter-associated thrombus formation. CT head was repeated post thrombectomy which confirmed stable SDH. He was not given any anticoagulation for 3 days before undergoing craniotomy and SDH drainage. He was started on apixaban 2.5 mg bd (twice daily) 7 days after thrombectomy. He remained free from PE recurrence and underwent elective retrieval of the IVC filter 3 months later. Residual below knee DVT were still visible on ultrasonography and therefore his apixaban dose was increased to 5 mg bd and continued for further 6 months.
Literature Review
Out of 1,752 publications screened by title and abstract, 53 reports fulfilled the inclusion and exclusion criteria. Full text articles were obtained, of which 31 articles were excluded from the final analysis. Therefore 22 articles were used for the final analysis (Table 1) [4,9-29]. Of these 22 publications, 17 were case reports, one was a case series of three patients, three were single centre retrospective reviews and one was a sub-analysis from the prospective, multi-centre RIETE (Computerized Registry of Patients with Venous Thromboembolism) registry. Together, they described the management and clinical outcomes of 148 patients with PE and concomitant ICB utilizing different treatment strategies.
Withholding Anticoagulation
Wijdicks et al. [9] reported their experience over two decades at the Mayo Clinic of 30 patients diagnosed with PE after strokes. Half the strokes were hemorrhagic in etiology and none of these patients were treated with anticoagulation after PE diagnosis. In this cohort of 30 patients, 15 died suddenly and the 15 who survived had major neurological deficits. It was not reported how many of the 15 who died suddenly had hemorrhagic strokes.
Anticoagulation Alone
Clinical outcomes of 102 patients with ICB and symptomatic PE, receiving anticoagulation were reported in the literature. Beyond case reports, there were 2 retrospective, single centre registries published. Chipman et al. [18] described 46 patients aged 16 years and above, traumatic ICB and concomitant PE. Nineteen out of 46 patients (41.3%) received anticoagulation early, at a median of 1.2 days after PE diagnosis and 8.8 days after injury whilst the remaining 27 received anticoagulation late, at a median of 4.6 days after PE diagnosis and 14 days after injury. In total, five patients (10.8%) had increased ICB after initiation of anticoagulation in the form of unfractionated heparin infusion, a numerically higher proportion of those who received anticoagulation early, although the difference was not statistically significant (early 17.6% vs. late 7.4%, P=0.30). Despite early anticoagulation, there were also four in-hospital deaths in this early subgroup, of which two were due to PE. Out of 46 patients, there were two (4.3%) cases of major bleeding requiring surgical intervention and 19 (41.3%) cases of minor bleeding or needed transfusion. In a smaller series of 36 ICB patients of which 70% were due to trauma, despite delaying the initiation of anticoagulation with heparin infusion until 9.5 days after ICB and only 40% of patients receiving therapeutic anticoagulation in the first week, six patients had hematoma expansion, of which 2 died as a result of worsened ICB [24]. Twelve percent of cases had minor extracranial bleeds that required interruption of anticoagulation. 15 out of 36 patients had concomitant DVT and 40% had an IVC filter implanted before the start of therapeutic anticoagulation. In the prospective RIETE registry, 60 patients with VTE, of which 16 had PE, underwent neurosurgery for ICB [16]. In these 60 patients, use of anticoagulation, initiated within 5 days of surgery, was associated with only one major bleeding complication but eight PE deaths, all within the first week of VTE therapy.
Systemic and Catheter-Directed Thrombolysis
Although acute ICB is an absolute contraindication to use of lytics, there were five cases reports of patients receiving systemic thrombolysis, all in cases with high-risk PE and associated with cardiac arrest in four out of five cases [12,14,15,21,27]. Worsened ICB and bleeding complications were seen in two out of five cases (40%). Survival status after thrombolysis was reported in only three cases, of which two survived to discharge.
There was one case report of catheter directed thrombolysis used in a patient with a thalamic hemorrhagic stroke 3 weeks prior to presentation with PE [25]. Pulmonary reperfusion was unsuccessful with suction thrombectomy (utilizing a Penumbra Cat-8 catheter) and clot fragmentation (using a Trerotola catheter). Therefore, 12.5 mg of tissue plasminogen activator was infused into each PA to avoid further cardiac arrest. No bleeding complications was reported and the patient was alive at 1 month post-intervention.
Surgical Embolectomy
Six patients were reported to have undergone surgical embolectomy, between 7 to 20 days after ICB [10,11,22,28]. Three cases had experienced cardiopulmonary arrest. There were no bleeding complications, and all patients survived to discharge.
Mechanical Thrombectomy without the Use of Thrombolytics
There were four prior single case reports of percutaneous mechanical thrombectomy for intermediate or high risk PE occurring 8 to 21 days after ICB [19,23,26,29]. Two cases were stabilized on venoarterial ECMO and one patient received inhaled nitrous oxide before undergoing thrombectomy. No bleeding complications or worsening of ICB were encountered. All procedures were acutely successful although one patient had recurrent PE which required repeated intervention with catheter-directed thrombolysis. All patients survived and three patients received IVC filters.
We presented two patients with significant SDH and symptomatic intermediate-high risk PE. To avoid the risk of worsening ICB by initiating anticoagulation and risk of PE death by withholding anticoagulation, both patients were successfully treated with mechanical thrombectomy, combined with IVC filter implantation to prevent embolization of detected DVT. This strategy treated PE symptoms, avoided further hemodynamic decompensation and allowed patients to undergo neurosurgery safely during an anticoagulation-free window.
Traditionally, treatment for symptomatic PE comprised of anticoagulation and in the event of hemodynamic compensation, systemic thrombolysis and in very few patients, surgical open chested embolectomy utilizing cardiopulmonary bypass (which also requires high levels of anticoagulation). However, all the treatment modalities are contraindicated in patients with concomitant ICB. The co-occurrence of PE and ICB is not uncommon. Withholding anticoagulation is associated with a high risk of in-hospital mortality [9]. As seen in our literature review, use of anticoagulation alone is associated with significant risk of bleeding complications, life-threatening ICB worsening and residual risk of early PE mortality. In recent years, the advent of catheter-directed therapies has provided additional treatment options for PE patients. Broadly these newer therapies can be classified as catheter-directed regional thrombolysis using lower doses of thrombolytics (typically less than 20% of the dose of systemic thrombolysis), administered via small-bore catheters (less than 7 Fr); or large bore (16 Fr or above) mechanical thrombectomy catheters that rely on suction to aspirate clots without the need for thrombolytics. There have been case reports of even low-dose regional thrombolysis causing or exacerbating pre-existing ICB [30]. Hence, catheter-directed thrombolysis would not be ideal for this high-risk patient cohort. The advent of thrombolytic-free suction thrombectomy with minimal blood loss provides an effective therapy to remove PE, restore normal pulmonary perfusion, normalize right heart hemodynamics and prevents hemodynamic compromise particularly during neurosurgery, with much theoretical lower risk of bleeding [8]. No bleeding complications or ICB worsening have been reported after mechanical thrombectomy in the literature. Based on limited cases, surgical embolectomy appears equally safe and effective. However, the procedure is much more invasive and contraindicated for patients with high surgical risk. Hence, surgical embolectomy was considered but considered too risky for a few patients who eventually underwent mechanical thrombectomy.
Seventy percent of PE patients will have ultrasonic evidence of DVT and the concomitant addition of an IVC filter will allow patients to interrupt anticoagulation for several days and proceed safely with neurosurgery [7]. Anticoagulation can be resumed post-neurosurgery without any pressing urgency, once the risk of post-operative bleeding is deemed to be sufficiently low.
The 2019 European Society of Cardiology guidelines on the management of PE carries a class IIa recommendation for the use of percutaneous catheter-directed treatments, as an alternative to rescue thrombolytic therapy, for intermediate risk patients with hemodynamic deterioration who have failed anticoagulation therapy. However, our patients represent a unique, not uncommon, subset of PE patients who are contraindicated for early anticoagulation and whilst may not have deteriorated hemodynamically, require reperfusion therapy for symptomatic improvement, prevent further decompensation and reduction of risk for general anesthesia and neurosurgery to occur [31].
Given the paucity of prospective data in the literature, the results of the literature review is subject to publication bias. Given the limited treatment options available to ICB patients, a prospective randomized study would be difficult to conduct. There is significant variation in the use of prophylactic anticoagulation, timing of initiating therapeutic anticoagulation amongst the cases described, which may have an influence on the clinical outcomes reported. Such treatments can only be performed in centers with experience in thrombolytic-free mechanical thrombectomy, which would limit the generalizability of these study findings.
In conclusion, combining thrombolytic-free mechanical thrombectomy with an IVC filter allows for effective PE treatment and temporary avoidance of anticoagulation whilst patients undergo neurosurgery for concomitant ICB. Such an approach and surgical embolectomy in selected patients with acceptable surgical risk seems safer and more clinically effective compared to withholding anticoagulation, use of anticoagulation alone and guidelines-contraindicated thrombolytic therapy.
▪ Intracranial bleeding (ICB) is associated with a higher risk of pulmonary embolism (PE).
▪ Even anticoagulation alone can result in elevated risks of intracranial hematoma expansion, extracranial bleeding and residual risk of PE mortality.
▪ Based on selected case reports only subject to publication bias, lytic-free mechanical thrombectomy and surgical embolectomy have been used successfully to treat PE in ICB patients without any bleeding complications and high survival to discharge rates reported.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: PK. Data curation: PK, KG, CYK, PC, PSSK. Formal analysis: PK. Methodology: PK. Writing – original draft: PK. Writing – review & editing: PK, KG, CYK, PC, PSSK. All authors read and agreed to the published version of the manuscript.

Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. PE: pulmonary embolism; VTE: venous thromboembolism.
acc-001075f1.jpg
Figure 2.
Head computed tomography showing traumatic right subdural hematoma.
acc-001075f2.jpg
Figure 3.
Computed tomography pulmonary angiography showing bilateral pulmonary emboli.
acc-001075f3.jpg
Figure 4.
(A) Suction thrombectomy of the right pulmonary artery. (B) Suction thrombectomy of the left pulmonary artery. (C) Contrast angiography confirming right pulmonary artery to be free from thrombus. (D) Contrast angiography confirming left pulmonary artery to be free from thrombus. (E) Clot removed from both pulmonary arteries displayed on an anatomical illustration of the pulmonary circulation. (F) Filter implanted in the inferior vena cava.
acc-001075f4.jpg
Figure 5.
Bilateral subdural hematoma on cerebral magnetic resonance scan.
acc-001075f5.jpg
Figure 6.
Computed tomography pulmonary angiography showing bilateral pulmonary emboli and right heart dilatation with right ventricular to left ventricular ratio of more than 1.
acc-001075f6.jpg
Figure 7.
Clot aspirated from both lungs in patient 2.
acc-001075f7.jpg
Figure 8.
Pulmonary thrombectomy of both right (A) and left (B) lungs. (C) Filter implanted in the inferior vena cava.
acc-001075f8.jpg
Table 1.
Studies reporting outcomes of patients with intermediate or high-risk PE and concomitant intracerebral bleeding
Study Study design No. of cases Type of ICB Time between ICB and PE ESC PE severity Time between PE diagnosis and treatment Cardiac arrest due to PE Worsened ICB / bleeding complications Survival to discharge Neurological deficit DVT / IVCF placed
Withholding anticoagulation
 Wijdicks et al. (1997) [9] Retrospective review 30 IS, 50%; HS, 50% 25/30 within 30 day NR No treatment given for those with HS NR No 50% (50% had sudden death) Major deficit in 15 patients 11/30, 8/11 IVCF
Anticoagulation alone
 Oneglia et al. (2008) [13] Case report 1 HS 16 day High Same day No No Yes None No
 Cote et al. (2014) [16] Prospective registry 16 /60 VTE Cerebral bleeding requiring neurosurgery 20 day NR NR NR NR NR NR NR
1 Major bleeding out of 60 3 PE deaths out of 60
 Lee et al. (2018) [17] Case report 1 HS 18 day High risk Same day No No Yes None No
Chipman et al. (2020) [18] Retrospective review Total: 46 Traumatic ICB 2.8 day NR 1.2 day 17.6% 79% NR 50% DVT, 21/46 IVCF
19 11.0 day 4.6 day 7.4% 100%
27 Extracranial:4.3% major bleeds requiring surgery, 41.3% minor bleeds or transfusions
 Chen et al. (2021) [20] Case report 1 HS (conversion from IS) 0 day Intermediate Same day No No Yes Right sided weakness Yes
 Becattini et al. (2021) [4] Case report 1 HS 7 day Intermediate Same day No No Yes Right hemiplegia Yes, IVCF
 Nguyen et al. (2022) [24] Retrospective review 36 ICB (70% trauma) 7.5 day NR 2 day NR 12% Worsened ICH, 2 deaths due hematoma expansion, 12% extracranial bleeds 12% Died from cardio-respiratory failure NR DVT, 15/36;
IVCF, 40%
Systemic thrombolysis
 Koroneos et al. (2007) [12] Case report 1 HS 24 day High risk 15 min Yes No NR NR NR
 Bottinor et al. (2014) [15] Case report 1 HS 56 day High risk 1 hr Yes No Yes NR Yes
 De Jong et al. (2013) [14] Case report 1 SAH 4 hr High risk 1 hr Yes Yes Yes Mild deficit NR
 Kong et al. (2021) [21] Case report 1 HS 13 day High risk 1 hr No Yes NR NR No
 Akanmode et al. (2023) [27] Case report 1 HS 1 day High risk Same day Yes No No NR NR
Catheter directed thrombolysis
 Rabai et al. (2022) [25] Case report (after failed mechanical thrombectomy) 1 HS 21 day High risk 1 hr Yes No Yes NR NR
Surgical embolectomy
 Endo et al. (2005) [10] Case report 1 ICB 11 day High risk Same day Yes No Yes NR NR
 Fukuda et al. (2006) [11] Case series 3 SDH, SAH, HS 7–16 day High risk 6–7 hr 2/3 No 100% None, 2/3; mild,1/3 NR
 Nasri et al. (2021) [22] Case report 1 HS 20 day Intermediate 24 hr No No Yes NR NR
 Tauzi et al. (2024) [28] Case report 1 HS 10 day High risk Same day No No Yes NR NR
Mechanical thrombectomy without the use of thrombolytics
 Mittal et al. (2020) [19] Case report 1 HS 8 day High risk 12 hr No No Yes No NR
Bridged with inhaled nitrous oxide
 Ciurylo (2022) [23] Case report 1 HS 9 day Intermediate Same day No No Yes No No
IVCF
 Reisinger et al. (2022) [26] Case report 1 HS 21 day High risk Yes Yes No Yes Moderate disability (mRS 3) Yes
Stabilized initially with ECMO IVCF
 Wang et al. (2024) [29] Case report 1 Traumatic SDH, SAH NR NR 4 day No No Yes NR Yes
Stabilized with ECMO IVCF

PE: pulmonary embolism; ICB: intracranial bleeding; ESC: European Society of Cardiology; DVT: deep vein thrombosis; IVCF: inferior vena cava filter; IS: ischemic stroke; HS: hemorrhagic stroke; NR: not reported; VTE: venous thromboembolism (PE plus DVT); SAH: subarachnoid hemorrhage; SDH: subdural hemorrhage; mRS: modified Rankin Scale; ECMO: extracorporeal membrane oxygenation.

  • 1. Knudson MM, Ikossi DG, Khaw L, Morabito D, Speetzen LS. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg 2004;240:490-6.ArticlePubMedPMC
  • 2. Ahmed N, Greenberg P, Shin SH. Pulmonary complications and sepsis following severe acute subdural hematoma in patients who underwent craniotomy versus craniectomy: a propensity score matched analysis. J Neurol Surg A Cent Eur Neurosurg 2020;81:297-301.ArticlePubMed
  • 3. Skaf E, Stein PD, Beemath A, Sanchez J, Bustamante MA, Olson RE, et al. Venous thromboembolism in patients with ischemic and hemorrhagic stroke. Am J Cardiol 2005;96:1731-3.ArticlePubMed
  • 4. Becattini C, Cimini LA, Carrier M. Challenging anticoagulation cases: a case of pulmonary embolism shortly after spontaneous brain bleeding. Thromb Res 2021;200:41-7.ArticlePubMed
  • 5. Divito A, Kerr K, Wilkerson C, Shepard S, Choi A, Kitagawa RS, et al. Use of anticoagulation agents after traumatic intracranial hemorrhage. World Neurosurg 2019;123:e25-30.ArticlePubMed
  • 6. 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.ArticlePubMed
  • 7. Kojodjojo P, Ong HA, Loh PH, Tay E, Chang P, Kuntjoro I, et al. First use of large-bore suction thrombectomy for acute pulmonary embolism in Asia-Pacific: feasibility and short-term clinical outcomes. J Thromb Thrombolysis 2023;55:660-6.ArticlePubMedPMCPDF
  • 8. Kojodjojo P, Ng CH, Ong KC, Zuzarte-Ng R, Chan WX. Large-bore suction thrombectomy for sub-massive pulmonary embolism during second trimester of pregnancy: a case report. Eur Heart J Case Rep 2023;7:ytad523.ArticlePubMedPMCPDF
  • 9. Wijdicks EF, Scott JP. Pulmonary embolism associated with acute stroke. Mayo Clin Proc 1997;72:297-300.ArticlePubMed
  • 10. Endo H, Kubota H, Sato M, Sudo K. Surgical treatment of pulmonary embolism with recent intracranial hemorrhage. Ann Thorac Cardiovasc Surg 2005;11:256-9.PubMed
  • 11. Fukuda I, Fukui K, Minakawa M, Koyama M, Ichinoseki I, Suzuki Y, et al. Rescue surgical embolectomy for fatal pulmonary embolism in patient with intracranial hemorrhage. Ann Thorac Surg 2006;81:735-7.ArticlePubMed
  • 12. Koroneos A, Koutsoukou A, Zervakis D, Politis P, Sourlas S, Pagoni E, et al. Successful resuscitation with thrombolysis of a patient suffering fulminant pulmonary embolism after recent intracerebral haemorrhage. Resuscitation 2007;72:154-7.ArticlePubMed
  • 13. Oneglia C, Gualeni A. Pulmonary embolism after brain hemorrhage in a hypertensive patient: the therapeutic dilemma. J Thromb Thrombolysis 2008;25:231-4.ArticlePubMedPDF
  • 14. De Jong A, Boularan A, Greco F, Khouri K, Perrigault PF. Successful rescue thrombolysis in massive pulmonary embolism with intracerebral hemorrhage. A A Case Rep 2013;1:31-3.ArticlePubMed
  • 15. Bottinor W, Turlington J, Raza S, Roberts CS, Malhotra R, Jovin IS, et al. Life-saving systemic thrombolysis in a patient with massive pulmonary embolism and a recent hemorrhagic cerebrovascular accident. Tex Heart Inst J 2014;41:174-6.ArticlePubMedPMCPDF
  • 16. Cote LP, Greenberg S, Caprini JA, Stone J, Arcelus JI, López-Jiménez L, et al. Outcomes in neurosurgical patients who develop venous thromboembolism: a review of the RIETE registry. Clin Appl Thromb Hemost 2014;20:772-8.ArticlePubMedPDF
  • 17. Lee WC, Fang HY. Management of pulmonary embolism after recent intracranial hemorrhage: a case report. Medicine (Baltimore) 2018;97:e0479. ArticlePubMedPMC
  • 18. Chipman AM, Radowsky J, Vesselinov R, Chow D, Schwartzbauer G, Tesoriero R, et al. Therapeutic anticoagulation in patients with traumatic brain injuries and pulmonary emboli. J Trauma Acute Care Surg 2020;89:529-35.ArticlePubMed
  • 19. Mittal A, Mittal AP, Rojas E, Al-Jaroushi H. Massive pulmonary embolism in a recent intracranial hemorrhage: a case report of inhaled nitric oxide to improve outcomes. Cureus 2020;12:e8218. ArticlePubMedPMC
  • 20. Chen XT, Zhang Q, Zhou CQ, Han YF, Cao QQ. Anticoagulant treatment for pulmonary embolism in patient with cerebral hemorrhage secondary to mechanical thrombectomy: a case report. World J Clin Cases 2021;9:10279-85.ArticlePubMedPMC
  • 21. Kong CY, Fu J, Li N, Xu ZH. Management of co-occurring intracranial hemorrhage and fatal pulmonary embolism: a case report. Chin Med J (Engl) 2021;134:1257-8.ArticlePubMedPMC
  • 22. Nasri MS, Abdelghani MS, Carr CS, Wani ML, Al-Hijji M. Successful surgical embolectomy for a rapidly deteriorating patient with pulmonary embolism and hemorrhagic stroke. Heart Views 2021;22:45-9.ArticlePubMedPMC
  • 23. Ciurylo W. Submassive pulmonary embolism in the setting of intracerebral hemorrhage: a case of suction thrombectomy. Cureus 2022;14:e32432. ArticlePubMedPMC
  • 24. Nguyen T, Sharma M, Crooks P, Patel PV, Bonow RH, Creutzfeldt CJ, et al. Between Scylla and Charybdis: risks of early therapeutic anticoagulation for venous thromboembolism after acute intracranial hemorrhage. Br J Neurosurg 2022;36:251-7.ArticlePubMed
  • 25. Rabai F, LaGrew JE, Lazarowicz M, Janelle GM, Goettel N, Caruso LJ, et al. High-risk pulmonary embolism after hemorrhagic stroke: management considerations during catheter-directed interventional therapy. J Cardiothorac Vasc Anesth 2022;36:3645-54.ArticlePubMed
  • 26. Reisinger AC, Fandler-Höfler S, Kreuzer P, Toth-Gayor G, Schmidt A, Gary T, et al. Va-ecmo and thrombus aspiration in a pulmonary embolism patient with cardiac arrest and contraindications to thrombolytic therapy. Vasa 2022;51:315-9.ArticlePubMed
  • 27. Akanmode OJ, Akanmode AM, Olusoji RA, Osanoto AS. Massive pulmonary embolus following a hemorrhagic stroke: a thrombolysis therapy dilemma. Cureus 2023;15:e37816. ArticlePubMedPMC
  • 28. Tauzi P, Aubourg C, Dang Van S, Gros A, Sargentini C, Rineau E, et al. A case report of pulmonary embolectomy under cardiopulmonary bypass in a patient with intracranial hemorrhage and history of heparin-induced thrombocytopenia. A A Pract 2024;18:e01767. ArticlePubMed
  • 29. Wang L, Ma C, Wang L, Ding Q, Yang H, Wang B, et al. Successful ECMO treatment in patients with cerebral hemorrhage and PROC gene mutation associated with VTE: a case report. Thromb J 2024;22:36.ArticlePubMedPMCPDF
  • 30. Sterling KM, Goldhaber SZ, Sharp AS, Kucher N, Jones N, Maholic R, et al. Prospective multicenter international registry of ultrasound-facilitated catheter-directed thrombolysis in intermediate-high and high-risk pulmonary embolism (KNOCOUT PE). Circ Cardiovasc Interv 2024;17:e013448. ArticlePubMedPMC
  • 31. Konstantinides SV, Meyer G. The 2019 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2019;40:3453-5.ArticlePubMedPDF

Figure & Data

References

    Citations

    Citations to this article as recorded by  

      • PubReader PubReader
      • ePub LinkePub Link
      • Cite
        CITE
        export Copy
        Close
        Download Citation
        Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.
        Format:
        • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
        • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
        Include:
        • Citation for the content below
        Managing symptomatic intermediate or high-risk pulmonary embolism presenting concomitantly with intracranial bleeding: case series and literature review
        Acute Crit Care. 2026;41(2):344-355.   Published online March 4, 2026
        DOI: https://doi.org/10.4266/acc.001075
        Close
      • XML DownloadXML Download
      Figure
      • 0
      • 1
      • 2
      • 3
      • 4
      • 5
      • 6
      • 7
      Managing symptomatic intermediate or high-risk pulmonary embolism presenting concomitantly with intracranial bleeding: case series and literature review
      Image Image Image Image Image Image Image Image
      Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. PE: pulmonary embolism; VTE: venous thromboembolism.
      Figure 2. Head computed tomography showing traumatic right subdural hematoma.
      Figure 3. Computed tomography pulmonary angiography showing bilateral pulmonary emboli.
      Figure 4. (A) Suction thrombectomy of the right pulmonary artery. (B) Suction thrombectomy of the left pulmonary artery. (C) Contrast angiography confirming right pulmonary artery to be free from thrombus. (D) Contrast angiography confirming left pulmonary artery to be free from thrombus. (E) Clot removed from both pulmonary arteries displayed on an anatomical illustration of the pulmonary circulation. (F) Filter implanted in the inferior vena cava.
      Figure 5. Bilateral subdural hematoma on cerebral magnetic resonance scan.
      Figure 6. Computed tomography pulmonary angiography showing bilateral pulmonary emboli and right heart dilatation with right ventricular to left ventricular ratio of more than 1.
      Figure 7. Clot aspirated from both lungs in patient 2.
      Figure 8. Pulmonary thrombectomy of both right (A) and left (B) lungs. (C) Filter implanted in the inferior vena cava.

      Figure 1.

      Figure 2.

      Figure 3.

      Figure 4.

      Figure 5.

      Figure 6.

      Figure 7.

      Figure 8.

      Managing symptomatic intermediate or high-risk pulmonary embolism presenting concomitantly with intracranial bleeding: case series and literature review
      Study Study design No. of cases Type of ICB Time between ICB and PE ESC PE severity Time between PE diagnosis and treatment Cardiac arrest due to PE Worsened ICB / bleeding complications Survival to discharge Neurological deficit DVT / IVCF placed
      Withholding anticoagulation
       Wijdicks et al. (1997) [9] Retrospective review 30 IS, 50%; HS, 50% 25/30 within 30 day NR No treatment given for those with HS NR No 50% (50% had sudden death) Major deficit in 15 patients 11/30, 8/11 IVCF
      Anticoagulation alone
       Oneglia et al. (2008) [13] Case report 1 HS 16 day High Same day No No Yes None No
       Cote et al. (2014) [16] Prospective registry 16 /60 VTE Cerebral bleeding requiring neurosurgery 20 day NR NR NR NR NR NR NR
      1 Major bleeding out of 60 3 PE deaths out of 60
       Lee et al. (2018) [17] Case report 1 HS 18 day High risk Same day No No Yes None No
      Chipman et al. (2020) [18] Retrospective review Total: 46 Traumatic ICB 2.8 day NR 1.2 day 17.6% 79% NR 50% DVT, 21/46 IVCF
      19 11.0 day 4.6 day 7.4% 100%
      27 Extracranial:4.3% major bleeds requiring surgery, 41.3% minor bleeds or transfusions
       Chen et al. (2021) [20] Case report 1 HS (conversion from IS) 0 day Intermediate Same day No No Yes Right sided weakness Yes
       Becattini et al. (2021) [4] Case report 1 HS 7 day Intermediate Same day No No Yes Right hemiplegia Yes, IVCF
       Nguyen et al. (2022) [24] Retrospective review 36 ICB (70% trauma) 7.5 day NR 2 day NR 12% Worsened ICH, 2 deaths due hematoma expansion, 12% extracranial bleeds 12% Died from cardio-respiratory failure NR DVT, 15/36;
      IVCF, 40%
      Systemic thrombolysis
       Koroneos et al. (2007) [12] Case report 1 HS 24 day High risk 15 min Yes No NR NR NR
       Bottinor et al. (2014) [15] Case report 1 HS 56 day High risk 1 hr Yes No Yes NR Yes
       De Jong et al. (2013) [14] Case report 1 SAH 4 hr High risk 1 hr Yes Yes Yes Mild deficit NR
       Kong et al. (2021) [21] Case report 1 HS 13 day High risk 1 hr No Yes NR NR No
       Akanmode et al. (2023) [27] Case report 1 HS 1 day High risk Same day Yes No No NR NR
      Catheter directed thrombolysis
       Rabai et al. (2022) [25] Case report (after failed mechanical thrombectomy) 1 HS 21 day High risk 1 hr Yes No Yes NR NR
      Surgical embolectomy
       Endo et al. (2005) [10] Case report 1 ICB 11 day High risk Same day Yes No Yes NR NR
       Fukuda et al. (2006) [11] Case series 3 SDH, SAH, HS 7–16 day High risk 6–7 hr 2/3 No 100% None, 2/3; mild,1/3 NR
       Nasri et al. (2021) [22] Case report 1 HS 20 day Intermediate 24 hr No No Yes NR NR
       Tauzi et al. (2024) [28] Case report 1 HS 10 day High risk Same day No No Yes NR NR
      Mechanical thrombectomy without the use of thrombolytics
       Mittal et al. (2020) [19] Case report 1 HS 8 day High risk 12 hr No No Yes No NR
      Bridged with inhaled nitrous oxide
       Ciurylo (2022) [23] Case report 1 HS 9 day Intermediate Same day No No Yes No No
      IVCF
       Reisinger et al. (2022) [26] Case report 1 HS 21 day High risk Yes Yes No Yes Moderate disability (mRS 3) Yes
      Stabilized initially with ECMO IVCF
       Wang et al. (2024) [29] Case report 1 Traumatic SDH, SAH NR NR 4 day No No Yes NR Yes
      Stabilized with ECMO IVCF
      Table 1. Studies reporting outcomes of patients with intermediate or high-risk PE and concomitant intracerebral bleeding

      PE: pulmonary embolism; ICB: intracranial bleeding; ESC: European Society of Cardiology; DVT: deep vein thrombosis; IVCF: inferior vena cava filter; IS: ischemic stroke; HS: hemorrhagic stroke; NR: not reported; VTE: venous thromboembolism (PE plus DVT); SAH: subarachnoid hemorrhage; SDH: subdural hemorrhage; mRS: modified Rankin Scale; ECMO: extracorporeal membrane oxygenation.

      Table 1.

      ACC : Acute and Critical Care
      © The Korean Society of Critical Care Medicine.
      TOP