Key result
A 66-year-old female with cerebral amyloid angiopathy and a left ventricular thrombus suffered a new ischaemic stroke despite treatment with apixaban 5 mg twice daily.
Why the study?
Anticoagulant treatment in patients with cerebral amyloid angiopathy presents a dilemma between significant intracerebral bleeding risk and high embolic stroke risk.
Case Report (n=1)
This case highlights the therapeutic dilemma and challenges of managing left ventricular thrombus with anticoagulation in patients with coexisting cerebral amyloid angiopathy due to competing risks of bleeding and thrombosis.
Poses therapeutic dilemma for LV thrombus anticoagulation in CAA; leaves open optimal strategy amid competing risks.
BACKGROUND: Cerebral amyloid angiopathy (CAA) is an important cause of cognitive impairment and spontaneous lobar intracerebral haemorrhage in older individuals. When necessary, anticoagulant treatment in these patients comes with two dilemmas; significant intracerebral bleeding risk with treatment vs. high risk of embolic stroke with no treatment. CASE SUMMARY: A 66-year-old female patient presented to the emergency clinic with a ST-elevation myocardial infarction. Her past medical history revealed cognitive problems associated with lobar cerebral microbleeds on magnetic resonance imaging suspect for probable CAA. A primary percutaneous coronary intervention of the left anterior descending artery with implantation of drug eluting stent was performed. Dual antiplatelet treatment was started initially. During hospitalization, an impaired left ventricular (LV) function was observed with an apical aneurysm. Six months after the initial event, LV function remained stable however a LV thrombus was observed. Apixaban 5 mg twice daily was started based on multidisciplinary consensus and on its efficacy and safety profile in patients with atrial fibrillation. Despite treatment, patient suffered a new ischaemic stroke probably from the LV thrombus, for which vitamin K antagonist treatment was initiated and Apixaban discontinued. DISCUSSION: Evidence for LV thrombus treatment with direct oral anticoagulants in CAA patients is scarce, however feasible based on its efficacy and safety profile. For CAA patients, the cardinal role of both clinical and radiological characteristics in determining the risk-benefit ratio for anticoagulant initiation in this specific subset of patients, is crucial. The clinical course described highlights the therapeutical dilemma of coexisting CAA and the clinical challenge it creates.
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Hilt et al. (2020) conducted a case report in Cerebral amyloid angiopathy and left ventricular thrombus (n=1). Apixaban was evaluated. A 66-year-old female with cerebral amyloid angiopathy and a left ventricular thrombus suffered a new ischaemic stroke despite treatment with apixaban 5 mg twice daily.
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