Submassive pulmonary embolism (PE) is defined as an acute PE without systemic hypotension but with either right ventricular (RV) dysfunction or myocardial necrosis.1 We report a case of a patient with submassive PE who developed intracranial bleeding following thrombolytic therapy.
A 47 years old lady who has underlying hypertension and a uterine fibroid fainted. GCS on arrival was E4 V1 M6 , BP 108/81, HR 120, SpO2 60% under room air, ECG showed Sinus tachycardia, RBBB and S1Q3T3. Bedside echocardiogram showed dilated RV , D shaped left ventricle and Mc Connell sign. D-dimer was > 20 and Trop I > 4000. Her SpO2 remained 80 % despite being on high flow mass. CT pulmonary angiogram showed multifocal bilateral lobar and segmental pulmonary artery embolisms. Intravenous alteplase was administered according to protocol. Her SpO2 improved to 100% and she was haemodynamically stable with a GCS of E4V4M6. The next day she complained of sudden onset of blurring of vision bilaterally. CT brain showed acute intraparenchymal hemorrhages at bilateral occipital lobes. She was diagnosed as bilateral eyes cortical blindness secondary to ICB post thrombolysis. Upon discharge she was able to walk and did not require any oxygen support however she still remained blind.
Discussion and conclusion
Thrombolytic therapy for submassive PE remains controversial. There is evidence of improvement of short term outcomes however there are increased risks of major haemorrhage in patients with submassive PE who receive thrombolysis.1 In conclusion, submassive PE requires careful evaluation and multi-disciplinary discussions regarding the decision to thrombolyse.
pulmonary embolism, thrombolytic therapy, blindness