Case Presentation: A 79-year-old male with cerebral amyloid angiopathy was admitted to the hospital due to the sudden onset of left-sided hemiparesis, sensory loss, neglect, facial palsy, and cognitive impairment. Upon neurological examination, the patient’s NIHSS score was determined to be 9, attributable to left-sided neglect, motor weakness, and facial palsy. CT head revealed a substantial mixed-density hemorrhage in the right frontal lobe. Labs revealed mild leukocytosis and normal coagulation panel.He was admitted due to an acute right frontal intracranial hemorrhage, which was secondary to cerebral amyloid angiopathy. This necessitated a stereotactic right frontal craniotomy for hematoma evacuation. Several days later, he developed an acute segmental pulmonary embolism (PE), which was managed with the placement of an inferior vena cava (IVC) filter due to contraindications for anticoagulation.Following the procedure, he had a syncopal episode. Further diagnostic workup, including a CT venogram of the abdomen and pelvis, revealed a large expansile thrombus extending from the IVC filter through the iliofemoral vasculature to the right popliteal vein. U/S confirmed the presence of a severe clot burden, with a thrombus extending from the IVC filter through the iliofemoral system to the right lower extremity popliteal vein.He was trialed of a low-intensity heparin nomogram, as the patient was not a candidate for lytic therapy due to his recent intracranial hemorrhage nor for mechanical thromboembolectomy. He was transitioned to therapeutic enoxaparin two days later.Subsequently, he demonstrated significant functional improvement and could ambulate 300 feet. He was discharged with outpatient follow-up with PT, OT, SLP, neurology, and vascular medicine. Following discharge, he tolerated therapeutic enoxaparin therapy for six weeks without any clinically significant hemorrhage. He was then transitioned to the factor Xa inhibitor (Apixaban) to complete a total of three months of anticoagulation therapy.
Discussion: Our patient presented with an acute spontaneous right frontal intracranial hemorrhage secondary to cerebral amyloid angiopathy, which was complicated by an acute segmental pulmonary embolism (PE), managed with IVC filter. However, the patient subsequently developed a large expansile thrombus extending from the IVC filter to the right popliteal vein, necessitating the initiation of anticoagulation.The decision to initiate anticoagulation was made after careful consideration in light of the IVC filter thromboembolism. A low-intensity heparin nomogram was trialed for several days, and he was thereafter transitioned to enoxaparin for several months to monitor for any hemorrhagic complications in light of cerebral amyloid angiopathy. Enoxaparin was favored in light of his ability to be rapidly reversed if hemorrhagic complications were to develop. He transitioned to Apixaban after six weeks. This stepwise approach to anticoagulation, coupled with close monitoring, allowed for the safe management without any clinically significant hemorrhage.
Conclusions: The management of patients with cerebral amyloid angiopathy who develop venous thromboembolism presents a unique clinical challenge, which is appropriately balancing and mitigating the risk of thromboembolism and managing the potential for bleeding while on anticoagulation. The patient’s successful outcome demonstrates the potential for safe and effective management of these complex clinical scenarios.