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SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira

OFFICIAL JOURNAL OF THE ASSOCIAÇÃO BRASILEIRA DE MEDICINA INTENSIVA AND THE SOCIEDADE PORTUGUESA DE CUIDADOS INTENSIVOS

ISSN: 0103-507X
Online ISSN: 1982-4335

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Rojas SSO, Veiga VC, Carvalho JC, Campodônico LEA, Assis FR, Shimizu SP, et al. Trombólise intra-arterial pulmonar no pós-operatório de clipagem de aneurisma cerebral. Relato de caso. Rev Bras Ter Intensiva. 2008;20(3):318-320

 

 

2008;20(3):318-320
Case Reports

http://dx.doi.org/10.1590/S0103-507X2008000300016

Intra-arterial pulmonary thrombolysis at the postoperative period of brain aneurysm clamping. Case report

Trombólise intra-arterial pulmonar no pós-operatório de clipagem de aneurisma cerebral. Relato de caso

Salomón Soriano Ordinola RojasI, Viviane Cordeiro VeigaII, Júlio César de CarvalhoII, Luis Enrique Amaya CampodônicoII, Fabrizio Rodrigues AssisII, Sandra Patrícia ShimizuIII, Olga Oliveira CruzIII, Elaine Aparecida MoraisIII, Roberto BuesioIV, Andréia Maria MarchesiniV, Ligia Maria Coscrato JunqueiraV, Carlos Vanderlei HolandaVI

IPhysician from the Neurological Intensive Care Units of the Hospital Beneficência Portuguesa de São Paulo, São Paulo (SP), Brazil
IIPhysician from the Neurological Intensive Care Units of the Hospital Beneficência Portuguesa de São Paulo, São Paulo (SP), Brazil
IIINurse from the Neurology Intensive Care Units of the Hospital Beneficência Portuguesa de São Paulo, São Paulo (SP), Brazil
IVPhysician from the Hospital Beneficência Portuguesa de São Paulo, São Paulo (SP), Brazil
VPhysiotherapist from the Intensive Care Units of the Hospital Beneficência Portuguesa de São Paulo, São Paulo (SP), Brazil
VIPhysician from the Hospital Beneficência Portuguesa de São Paulo, São Paulo (SP), Brazil

Submitted on June 24, 2008
Accepted on August 14, 2008

Corresponding author:

Viviane Cordeiro Veiga MD
Alameda Hungria, 89 - Alphaville
06474-140 Barueri, (SP), Brazil
Phone/Fax: (11) 3262-3512
E-mail: [email protected]

 

Abstract

Pulmonary thromboembolism is a major cause of morbidity and mortality of patients undergoing neurosurgical procedures. The purpose of this study was to present a case of intra-arterial pulmonary thrombolysis in recent neurosurgery postoperative period. Male patient, undergoing neurosurgery, presented as a complication on the seventh day of postoperative massive pulmonary embolism with hemodynamic instability and intra-arterial pulmonary thrombolysis with alteplase was indicated. Evolution was satisfactory without bleeding complications and patient was discharged. Pulmonary thromboembolism is a high morbidity and mortality condition at neurosurgical postoperative period and thrombolysis should be an alternative therapy in cases refractory to clinical treatment.

Keywords: Intracranial aneurysm/surgery; Intracranial aneurysm/complications; Pulmonary embolism/etiology; Postoperative period; Thrombolytic therapy; Case reports

 

 

INTRODUCTION

Pulmonary thromboembolism (PT) is a leading cause of morbimortality in patients submitted to neurological procedures1,2. For cases of PT in patients in recent postoperative of neurosurgery, thrombolytic therapy is contraindicated and only performed in selected cases2. The objective of this study was to report a case of a patient that presented with a massive pulmonary tromboembolism in the seventh postoperative day of a cerebral aneurism clamping, submitted to intra-arterial thrombosis, with a good outcome.

 

CASE REPORT

Male, 36 year old patient with a diagnosis of anterior communicating artery aneurysm, with indication for surgical treatment. As previous event he presented with ischemic stroke in the occipital region.

He was admitted at the intensive care unit (ICU) at immediate postoperative period of anterior communicating artery aneurysm clamping without intercurrence, and was discharged from the ICU on the second postoperative day.

On the seventh postoperative day he presented with precordial burning pain, together with tachycardia, cold sudoresis and hemodynamic instability, and was transfer to the ICU requiring administration of vasoactive drugs and oxygen.

The electrocardiogram disclosed dispersed alteration of ventricular repolarization. Transthoracic echocardiogram showed dilation of the right chamber and dysfunction of the right ventricle without other significant alterations. A computed tomography angiography of the chest was requested showing filling defects in both pulmonary arteries and their segmentary branches, related to an extensive bilateral pulmonary thromboembolism (Figures 1 and 2).

Thereupon invasive hemodynamic monitoring was chosen with a Swan-Ganz catheter, initially presenting with a cardiac index of 2 L/min and mean pulmonary artery pressure of 37 mmHg. Patient was hypotensive, receiving noradrenaline and dobutamine, without clinical improvement. During hematological investigation a protein C deficiency and resistance to activated protein C were detected.

Because of the condition's severity, intravenous heparin was introduced in a 60 UI/kg dose and, later, intra-pulmonary arterial thrombolysis with maneuvers of mechanical fibrinolysis and injection of 20mg of alteplase (rt-PA) in bolus. This was followed by 30 mg of the same substance intravenously, with improvement of the clinical, hemodynamic and angiographic parameters which allowed for reduction of vasoactive drugs.

Intravenous heparin was maintained in continuous infusion for 72 hours with control of activated partial thromboplastin time (APTT) between 1.5 - 2.0 times the normal values. Low molecular weight heparin (enoxaparin) 1 mg/kg subcutaneous every 12 hours was introduced, as from the fourth day of thrombolysis.

Patient remained stable, presenting as only post-thrombolysis intercurrence a discreet bleeding at the site of the vascular puncture. He did not present neurological deficits and was discharged from the ICU and later from the hospital.

 

DISCUSSION

Pulmonary thromboembolism is a severe condition affecting about 2.5% of hospitalized patients, with a mortality of over 30% in cases of massive PT3,4.

Included among predisposing factors are extensive surgical procedures, prolonged immobilization, stroke, chronic venous insufficiency of the lower limbs, in addition to disorders of the coagulation system such as antithrombin III, protein S and protein C3,5, deficiency. In such cases diagnosis is mostly achieved after the thrombotic event. In this case the patient presented more than one predisposing factor for the condition, that is to say, the protein C deficiency and neurosurgical procedure.

After diagnosis, risk stratification was required and patients who present hemodynamic instability, respiratory failure or right ventricle dysfunction at echocardiogram, were considered of high risk. In these cases, anticoagulation and use of fibrinolysis (thrombolysis), in addition to oxygen supplement, were indicated for correction of hypoxia and administration of fluids to maintain preload of the right ventricle6,7. This patient had hemodynamic instability and right ventricle dysfunction. However, as he was at recent postoperative period (seventh day) from cerebral aneurism clamping, there was a contraindication for use of a thrombolític8-10. Nevertheless, because he was hemodynamically unstable, requiring high concentrations of vasoactive drugs, intra-arterial thrombolysis was chosen, with rigorous observation of the clinical parameters essentially related to possible hemorrhagic complications.

Pulmonary thromboembolism is a high morbidity and mortality condition at neurosurgical postoperative period and thrombolysis should be an alternative therapy in cases refractory to clinical treatment.

 

REFERENCES

01. Inci S, Erbengi A, Berker M. Pulmonary embolism in neurosurgical patients. Surg Neurol. 1995;43(2):123-8; discussion 128-9.

02. Kutlu R, Alkan A, Kocak A, Sarac K. Thrombolysis and mechanical fragmentation to treat massive pulmonary embolism in a patient with an anterior communicating artery aneurysm. J Endovasc Ther. 2003;10(2):332-5.

03. De Gregorio MA, Gimeno MJ, Mainar A, Herrera M, Tobio R, Alfonso R, et al. Mechanical and enzymatic thrombolysis for massive pulmonary embolism. J Vasc Interv Radiol. 2002;13(2 Pt 1):163-9.

04. Sayeed RA, Nashef SA. Successful thrombolysis for massive pulmonary embolism after pulmonary resection. Ann Thorac Surg. 1999;67(6):1785-7.

05. Wood KE. Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism. Chest. 2002;121(3):877-905. Comment in: Chest. 2002;122(6):2264; author reply 2264-5.

06. Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J. 2000; 21(16):1301-36. Review.

07. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353(9162):1386-9. Comment in: Lancet. 1999;353(9162):1375-6.

08. di Ricco G, Marini C, Rindi M, Ravelli V, Lutzemberger L, Tusini G, Giuntini C. Pulmonary embolism in neurosurgical patients: diagnosis and treatment. J Neurosurg. 1984;60(5):972-5.

09. Endo H, Kubota H, Sato M, Sudo K. Surgical treatment of pulmonary embolism with recent intracranial hemorrhage. Ann Thorac Cardiovasc Surg. 2005;11(4):256-9.

10. Chalela JA, Katzan I, Liebeskind DS, Rasmussen P, Zaidat O, Suarez JI, et al. Safety of intra-arterial thrombolysis in the postoperative period. Stroke. 2001;32(6):1365-9. Rev Bras Ter Intensiva. 2008; 20(3):318-320

 

 

Received from the Neurology Intensive Care Units of the Hospital Beneficência Portuguesa, São Paulo, (SP), Brazil.

 

 

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