Traumatic Brain Injury and Pulmonary Embolism [Neurosurgery Wiki]

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====== Traumatic Brain Injury and Pulmonary Embolism ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1-9bVabsJ_0-cbNHnd8bBAx-lW7AUXphPCfuUSBS2NWTxxGg0f/?limit=15&utm_campaign=pubmed-2&fc=20241112132347}}

[[Severe traumatic brain injury]] (sTBI) is a silent epidemic, causing approximately 300,000 intensive care unit (ICU) admissions annually, with a 30% mortality rate. Despite worldwide efforts to optimize the management of patients and improve outcomes, the level of evidence for the treatment of these patients remains low. The concomitant occurrence of [[thromboembolic event]]s, particularly pulmonary embolism (PE), remains a challenge for intensivists due to the risks of [[anticoagulation]] to the injured brain. 
Vrettou et al. performed a literature review on sTBI and concomitant PE to identify and report the most recent advances on this topic. They searched PubMed and Scopus for papers published in the last five years that included the terms "pulmonary embolism" and "traumatic brain injury" in their title or abstract. Exclusion criteria were papers referring to children, non-sTBI populations, and post-acute care. Our search revealed 75 papers, of which 38 are included in this review. The main topics covered include the prevalence of and risk factors for pulmonary embolism, the challenges of timely diagnosis in the ICU, the timing of pharmacological prophylaxis, and the treatment of diagnosed PE
((Vrettou CS, Dima E, Karela NR, Sigala I, Korfias S. Severe Traumatic Brain Injury and Pulmonary Embolism: Risks, Prevention, Diagnosis and Management. J Clin Med. 2024 Aug 2;13(15):4527. doi: 10.3390/jcm13154527. PMID: 39124793; PMCID: PMC11313609.)).

===== Case report =====
### Case Report: Management of Traumatic Brain Injury with Concurrent Pulmonary Embolism in an Elderly Patient

**Patient Information:**
- **Age/Sex**: 89-year-old female
- **Relevant Medical History**:
  - Hypertension
  - Type 2 Diabetes Mellitus
  - Dyslipidemia
  - Prior surgeries: Appendectomy, polypectomy
  - [[Pulmonary embolism]]

**Medications:**
- **Chronic**: Artedil, Atorvastatin, Omeprazole, Icandra, Sutrill Neo, Sintrom, Lexatin, Adenuric (limited course), Torasemide, Xalatan, Noctamid.

**Presenting Complaint:**
The patient was admitted following a fall while getting out of bed, which resulted in head trauma with a confirmed [[traumatic subarachnoid hemorrhage]] (SAH) and nasal fracture.

**Examination:**
- **Initial Presentation**: Alert, GCS 15, oriented with preserved language and no focal neurological deficits.
- **Vital Signs**: Normotensive, afebrile, normocolored, and normoperfused.
- **Neurological Examination**: No syncope, seizures, or signs of neurological deficit were observed.

**Imaging and Diagnostics:**

1. **Initial CT Head**:
   - Right frontal SAH adjacent to the frontal [[operculum]].
   - Nasal bone fracture and soft tissue swelling around the periocular and frontal regions.
   - Findings suggestive of chronic small vessel ischemic changes.
  
2. **Repeat CT Head**:
   - Persistent right frontal SAH, slightly reduced.
   - New frontal right subdural hematoma, ~5 mm without mass effect, likely subacute.
   - Recommended MRI for further evaluation of the subdural hematoma.

3. **CT Pulmonary Angiogram**:
   - Segmental and subsegmental [[pulmonary embolism]] (PE) in the right lung.
   - Slightly enlarged pulmonary artery, stable from a prior study.
   - Minimal pleural effusion and bibasal atelectasis.
   - Hiatal hernia containing part of the stomach.

4. **Venous Doppler of Lower Limbs**:
   - No signs of deep vein thrombosis (DVT) in either limb.

**Treatment:**

1. **Pulmonary Embolism Management**:
   - [[Vena cava filter]] (OptionElite) placed via femoral access to reduce embolic risk, considering the contraindication to [[anticoagulation]].
   - Anticoagulation with Sintrom was suspended temporarily, with planned reassessment after one month for possible reinitiation.

2. **Brain Injury Management**:
   - Conservative treatment for the SAH and subdural hematoma, with planned MRI for further evaluation.
   - Neurological monitoring with frequent assessments for changes in consciousness or new focal deficits.

3. **Supportive Care**:
   - Diuretic therapy (Seguril) and continuation of chronic medications, except for temporarily held anticoagulant.
   - Initiated domiciliary oxygen therapy (2 L/min for 18 hours daily) due to hypoxemic risk.
   - Pain managed with oral analgesics; no adverse events related to deambulation or oral intake.

**Outcome and Follow-Up:**
The patient remained hemodynamically stable and neurologically intact during hospitalization. There were no signs of DVT or clinical worsening, and she tolerated all supportive interventions. A follow-up plan includes primary care for regular monitoring and re-evaluation by Hematology for anticoagulation therapy in one month.

**Discussion:**
This case highlights the complexities in managing [[traumatic brain injury]] with concurrent [[venous thromboembolism]]s in an elderly patient with significant comorbidities. Treatment required balancing the risks of anticoagulation in the presence of intracranial hemorrhage with the high risk of recurrent embolic events. The placement of a vena cava filter allowed temporary suspension of anticoagulation, mitigating the embolic risk. Conservative management for the SAH and subdural hematoma proved effective, with no need for surgical intervention. The patient’s stable course underscores the potential for successful outcomes with a multidisciplinary, conservative approach in similar complex cases.

**Conclusion:**
[[Elderly patient]]s with [[traumatic subarachnoid hemorrhage]] and concurrent [[pulmonary embolism]] can be managed effectively with [[conservative treatment]], close monitoring, and selective use of interventional strategies like [[vena cava filter]]s. This case demonstrates the importance of individualized care, especially when managing potentially conflicting conditions like [[hemorrhagic stroke]] and thromboembolic disease.