Subdural hematomas in pulmonary arterial hypertension patients treated with prostacyclin analogs
The first patient is a 64-year-old Caucasian female with a diagnosis of idiopathic PAH made in July 2005. Her other past medical history includes essential hypertension, hyperlipidemia, type II diabetes mellitus, and coronary artery disease status post percutaneous coronary intervention with stent placement. The patient was in NYHA Functional Class III. Right heart catheterization showed a mean pulmonary artery pressure of 41 mmHg, cardiac index of 2.2 l/min/m2, and mixed venous O2 saturation of 72%. Echocardiogram showed moderate-to-severe right ventricular dilation with moderate right ventricular dysfunction. The patient started treatment for PAH with the intravenous prostacyclin analog treprostinil in August of 2005. In addition to the prostacyclin analog, the patient received aspirin 81 mg daily, clopidogrel 75 mg daily, and warfarin 3 mg daily. After seven months of this treatment and without any trauma, the patient presented to her local hospital with new onset confusion. Her dose of treprostinil at this time was 58 ng/kg/min. A computed tomography (CT) scan showed an acute subdural hematoma (, panel A). Her blood work prior to her intracranial bleed showed a low normal platelet count of 162,000/uL and an international normalized ratio (INR) of 2.7. The patient's clopidogrel and warfarin were discontinued. Her neurologic status remained stable. She was continued on treprostinil for treatment of her pulmonary hypertension. She had no residual neurological deficits as result of her bleed.