Key result
Staged antithrombotic reinitiation enables successful management of concurrent STEMI, LV thrombus, and intracerebral hemorrhage.
Why the study?
No guideline addresses the timing, sequence, or agent selection for antithrombotic management when recent stenting, left ventricular thrombus, and intracerebral hemorrhage converge.
Case Report (n=1)
In patients with converging indications for anticoagulation and dual antiplatelet therapy complicated by intracerebral hemorrhage, staged reinitiation starting with short-acting agents guided by neuroimaging may be a viable strategy.
Answers are grounded in this paper and cite their sources.
Individualized antithrombotic sequencing may be required after ICH with recent stenting and LV thrombus; extends sparse case evidence for unresolved guideline gaps.
BACKGROUND: Left ventricular thrombus after anterior ST-segment elevation myocardial infarction requires anticoagulation, and recent stenting requires dual antiplatelet therapy, but no guideline addresses antithrombotic sequencing when intracerebral hemorrhage complicates both. CASE SUMMARY: A 63-year-old woman developed an apical left ventricular thrombus after left anterior descending artery percutaneous coronary intervention for late anterior ST-segment elevation myocardial infarction, then a left temporal intracerebral hemorrhage on day 2 while receiving aspirin, ticagrelor, and heparin. Declining ejection fraction and enlarging thrombi prompted staged reinitiation: cangrelor, clopidogrel, unfractionated heparin, then apixaban after serial neuroimaging confirmed stability. WHY BEYOND THE GUIDELINES: No guideline addresses the timing, sequence, or agent selection when these 3 indications converge. DISCUSSION: Staged reinitiation with short-acting and reversible agents may allow antithrombotic escalation guided by serial neuroimaging stability. TAKE-HOME MESSAGE: When competing thrombotic and hemorrhagic risks fall outside guideline pathways, antithrombotic therapy can be reintroduced in reassessable steps, starting with short-acting agents, guided by serial neuroimaging.
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Mokrytzki et al. (2026) conducted a case report in STEMI complicated by LV thrombus and intracerebral hemorrhage (n=1). Staged antithrombotic reinitiation was evaluated. Staged antithrombotic reinitiation allowed successful treatment in a 63-year-old woman with concurrent STEMI, LV thrombus, and intracerebral hemorrhage.
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