Both sides of the story – cerebral infarction after intra-abdominal bleeding

Excerpt

We report the case of a 36-year-old female patient who was diagnosed with acute pulmonary sarcoidosis and liver infiltration in a general care hospital. In this context following percutaneous liver biopsy the patient developed overt hemorrhagic shock due to intra-abdominal bleeding. Immediately laparatomy with intraabdominal packing was performed, however, control of bleeding was not achieved. Therefore the patient was referred to our hospital. Before transport 30 red cell concentrates, 3 thrombocyte concentrates, 18 units of fresh frozen plasma, 10.000 IU antithrombin III, 8.000 IU prothrombin complex concentrate and 9 g fibrinogen had been administered without clinical benefit. An abdominal CT scan showed a large central parenchymal haematoma with capsular rupture and hemoperitoneum (Fig. 1). Upon admission we immediately decided to perform a second surgical intervention with optimised perihepatic packing. Subsequently recombinant factor VIIa (NovoSeven®) was given as a single bolus of 90 μg/kg body weight. Consequently no further substitution of erythrocyte concentrates was necessary until discharge. Initially the clinical situation was complicated by signs of liver failure. After stabilisation and discontinuing of analgosedatives however the level of consciousness did not improve adequately. The patient showed mental disorder with delirant symptoms. At this time cranial MRI scan showed bilateral cerebral infarction of the anterior and occipital lobes and ischemic lesions in both thalami. (Fig. 2) In summary subacute thromboembolic events are the only plausible cause of the observed neurologic impairment …