Subdural hematomas in pulmonary arterial hypertension patients treated with prostacyclin analogs
The second patient is a 46-year-old female with a diagnosis of mixed pulmonary arterial and pulmonary venous hypertension made in February of 2008. She began treatment with the inhaled prostacyclin analog iloprost in April of 2008. Her other past medical history included paroxysmal atrial fibrillation and history of rheumatic heart disease status post mitral and aortic valve replacement with mechanical prosthetic valve. The patient was in NYHA Functional Class III. Right heart catheterization showed a right atrial pressure of 17 mmHg and a right ventricular pressure of 132/2 mmHg. Pulmonary artery pressure could not be directly measured due to the inability to advance the catheter into the pulmonary artery. Her echocardiogram showed moderately dilated right ventricle with moderately decreased right ventricular systolic function. The patient was admitted to our hospital in December of 2009 for evaluation of dyspnea when she developed new onset headaches. The dose of iloprost at that time was 6 inhalations per day of 5 mcg. A CT scan of the brain showed multiple acute and subacute subdural hematomas overlying the cerebral hemispheres and left posterior fossae (, panel B). At the time of her bleed, the patient was also taking aspirin 81 mg daily. She was receiving therapeutic anticoagulation with heparin for her mechanical valve with an activated partial thromboplastin time (aPTT) value of 71.2 seconds. She was noted to have mild thrombocytopenia with a count of 145,000/uL. The patient's anticoagulation therapy was held and she did not have any neurologic sequelae from her bleed. Her anticoagulation therapy was later resumed with a lowered target INR of 1.5-2. She had no further known episodes of bleeding afterwards.