Subdural hematomas in pulmonary arterial hypertension patients treated with prostacyclin analogs
The third patient is a 58-year-old female with idiopathic PAH who had been receiving intravenous epoprostenol since November 2010. She was in NYHA Functional Class I/II. Right heart catheterization showed mean right atrial pressure of 4 mmHg, pulmonary artery pressure of 65/32, mean pulmonary artery pressure of 43 mmHg, a cardiac index of 2.2 l/min/m2, and mixed venous O2 saturation of 60%. Her echocardiogram showed moderate right ventricle dilation with moderate right ventricle systolic dysfunction. Her other relevant past medical history includes essential hypertension, type II diabetes mellitus on insulin therapy, and depression. Five months after the initiation of epoprostenol, the patient presented to local hospital with headache, nausea, disorientation, and gait difficulties. The dose of epoprostenol was 30 ng/kg/min. She underwent CT scan of the head which showed subacute subdural hematomas involving the left frontoparietal and right frontal areas. The patient was receiving warfarin at the time of her bleed. Blood work revealed thrombocytopenia with a platelet count of 94,000/uL and INR of 2.4. Anticoagulation therapy was discontinued. She was followed by our neurosurgical team who observed interval resolution of her hematomas. Patient recovered without significant neurologic deficits. She was subsequently continued on epoprostenol.