22. European Stroke Conference 187 Interesting and challenging cases Recurrent Stroke in Correctly Anticoagulated Patient with Complex Atheromatosis and Su-perimposed Thrombus of the Aortic Arch J.F. Carvalho1, T. Ramires2, C.M. Corzo3, S. Lourenço4, C. Barata5, J. Vasconcelos6, L. Rebocho7 Hospital do Espírito Santo de Évora, Évora, PORTUGAL1, Hospital do Espírito Santo de Évo-ra, Évora, PORTUGAL2, Hospital do Espírito Santo de Évora, Évora, PORTUGAL3, Hospital do Espírito Santo de Évora, Évora, PORTUGAL4, Hospital do Espírito Santo de Évora, Évora, POR-TUGAL5, Hospital do Espírito Santo de Évora, Évora, PORTUGAL6, Hospital do Espírito Santo de Évora, Évora, PORTUGAL7 Background: Complex atheromatosis of the aortic arch is a known etiology of cryptogenic stroke and its early detection is primordial to avoid recurrent events, especially in patients with high-risk features in Transoesophageal echocardiography (TOE), like large plaques and superimposed throm-bus. There are few evidence-based strategies to secondary prevention in this subgroup of patients and the debate continues surrounding anti-platelet therapy alone or double anti-platelet therapy or anticoagulation. Case-report: We describe the case of a 59-year old male, with history of hypertension, active smok-ing (40 pack-years), hypercolesterolemya and previous right PCA ischemic stroke due to large (11 mm) complex atherosclerotic plaques in the aortic arch and descending aorta, whereby he started statin therapy and oral anticoagulation with Warfarin to a target INR 2.0-3.0. Six months later, he presented with abrupt onset disartria, left central facial palsy and left hemiparesia. Brain MRI re-vealed an acute right fronto-insular infarction (right MCA stroke), despite of therapeutic range INR (2.27). TOE revealed a thickness reduction (<4mm) of the aforementionated plaques but a new su-perimposed thrombus (1.2x6 mm) in the aortic arch. Aspirin 100 mg/daily was given in addition to oral anticoagulation in the aforementionated range and, at 1-year follow-up, no recurrences occured. Conclusion: This case shows that patients with large complex atherosclerotic plaque and a mobile thrombus in the aortic arch have an increased risk for recurrent stroke despite oral anticoagulation. In the absence of randomized studies to guide the best evidence-based treatment to our patient, we decided to add low-dose aspirin to prevent recurrent thrombo-embolic events, with sucess. Due to insufficient data available, we emphatize the need of prospective randomized studies to evaluate which treatment strategies have more efficacy in the prevention of recurrent events in this subgroup of patients. 382 © 2013 S. Karger AG, Basel Scientific Programme 188 Interesting and challenging cases The Management of Intracerebral Haemorrhage in patients with mechanical heart valves re-quiring antiocagulation. H. Khambay1, F. Gergely,2, D. Hargroves3, T. Webb4, I. Balogun5 East Kent Stroke Service,, Ashford, UNITED KINGDOM1, East Kent Stroke Service, Ashford, UNITED KINGDOM2, East Kent Stroke Service, Ashford, UNITED KINGDOM3, East Kent Stroke Service, Ashford, UNITED KINGDOM4, East Kent Stroke Service, Ashford, UNITED KINGDOM5 Anticoagulation for patients with mechanical heart valves (MHV) is required due to high risk of thromboembolism. Anticoagulants such as Warfarin increase risk of bleeding, including intracere-bral haemorrhage (ICH). Clinicians are faced with a difficult decision when managing ICH in pa-tients with MHV’s in order to balance the risk of thromboembolism with ICH extension. In the ab-sence of randomized trial evidence consensus guidance suggests patients may be safe to wait up to 2 weeks without anticoagulation. We report a patient with an aortic and mitral MHV, anticoagulated with Warfarin who suffered an ICH when INR was therapeutic, a further ICH extension at 3 months when re anticoagulated, fol-lowed by a cardioembolic stroke when anticoagulation was with held for less than 2 weeks. An 85-year-old man with aortic and mitral MHV, presented with a non disabling right parietal ICH, confirmed by CT imaging. Admission INR was 3.2. 10mg Vitamin K was given intravenously. Fol-lowing three days without anticoagulation he was treated with an IV heparin infusion, target Heparin ratio 2-3, for ten days. This was then replaced with 1.5mg per kg dose of subcutaneous Enoxaparin (120 mg daily). He returned home, only to return three months later with a further symptomatic, but again non disabling right parietal ICH. Anticoagulation was once again corrected and withheld, but at day13 he suffered a disabling right MCA ischaemic stroke syndrome. He was commenced upon 60mg daily subcutaneous Enoxaparin. His condition failed to improve significantly. He was dis-charged home requiring nursing care, modified rankin scale = 4. Our case highlights the challenge for re-initiating anticoagulation following ICH in patients with MHV’s. Even when anticoagulation is withheld for less than 14 days cardioembolic stroke may oc-cur. Further research is urgently required to guide clinicians. We recommend a ward-based risk as-sessment and use of prognostic tools to support clinicians until such time.
Karger_ESC London_2013
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