When a Pulmonary Embolism Precedes the Fall: Anticoagulation Challenges in Traumatic Intracranial Hemorrhage

Pulmonary embolism (PE) is typically managed with urgent systemic anticoagulation or reperfusion therapy. However, management becomes complex when PE occurs concurrently with traumatic intracranial hemorrhage (ICH), where anticoagulation may worsen bleeding. A 74-year-old male patient presented after syncope and traumatic head injury. He was hypoxic and tachycardic on arrival with concern for right ventricular strain. Given persistent clinical concern, CT angiography of the chest demonstrated a massive saddle PE. CT of the head revealed traumatic subarachnoid hemorrhage and a small subdural hematoma with an occipital skull fracture, with no midline shift/mass effect, and an admission Glasgow Coma Scale (GCS) of 15/15. He underwent urgent mechanical thrombectomy with inferior vena cava (IVC) filter placement. A cautious heparin infusion was initiated without a bolus following neurosurgical approval and close neurological monitoring. Early repeat CT demonstrated interval hemorrhage progression, but subsequent imaging showed stability. His activated partial thromboplastin time (aPTT) was titrated carefully without clinical deterioration, and he was transitioned to apixaban without a loading dose. He remained neurologically stable and improved clinically prior to discharge. This case illustrates the competing priorities of preventing fatal thromboembolism while minimizing hemorrhagic progression in traumatic ICH. Mechanical thrombectomy, serial imaging, and staged anticoagulation guided by multidisciplinary collaboration allowed safe re-initiation of anticoagulation.