Stroke Patient Discharged With New Brain Bleed

Case Overview

This case involves a thirty-seven-year-old woman with a medical history of a mitral valve replacement. The patient presented to the emergency room with severe weakness in the left upper extremity and impaired coordination. A CT was performed and the initial impression showed a right hemispheric cortical ischemic event. A decision was made to transfer the patient to a tertiary care hospital for CT angiography and CT profusion. A right ICA angiogram was performed and the cranial run revealed a right M1 occlusion. She then underwent a thrombectomy with a Merci thrombolysis L6 system. Records show that anticoagulation therapy during the admission for the M1 occlusion included a heparin drip at a rate of 700units/hr. Orders were also issued for Coumadin five milligrams and for 5000U of heparin. In addition to the Coumadin and heparin, the patient was started on Plavix and aspirin. The patient was discharged after the final INR levels were found to be three. The patient was told to follow up with her doctor in six weeks and to make an appointment to follow up with cardiology for her INR level. The next day, the patient awoke and began vomiting and experienced a severe temporal headache. After EMS rushed her back to the hospital, a CT of the brain without contrast described a new evolving parenchymal hemorrhage in the right temporal and frontoparietal lobes. Her INR on this admission was found to be ten. The patient underwent an emergency, right-sided hemicraniectomy and was taken off Coumadin and aspirin due to her bleed. The patient was discharged to a rehabilitation facility with significant motor weakness, facial droop, and slurred speech. Subsequently, the patient currently required assistance in all aspects of daily living.