Left-atrial-appendage-closure (LAAC) is suggested as alternative to antiplatelet/ anticoagulant therapy (AP/AC) for stroke-prevention in patients with cerebralamyloid-angiopathy (CAA), intracerebral hemorrhage (ICH) and atrial fibrillation (AF). Disadvantages of LAAC are the need for postinterventional AP and impairment of left atrial function, thus promoting heart-failure. Therefore, in an 83-year-old edoxaban-treated AF-patient with ICH and CAA, only antihypertensive therapy with neither AP/AC nor LAAC was recommended. Twenty-seven months without stroke/ICH support this strategy, which needs confirmation by a randomized-trial. K E Y W O R D S anticoagulant therapy, atrial fibrillation, cerebral amyloid angiopathy, cerebral bleeding, left atrial appendage closure How to cite this article: Stöllberger C, Finsterer J, Schneider B. Stroke prevention in an octogenarian with atrial fibrillation, cerebral amyloid angiopathy and intracerebral hemorrhage.

Introduction: Left ventricular (LV)-thrombi occur in up to 14% of patients with acute myocardial infarction (AMI) in the era of primary percutaneous coronary intervention. For these patients, anticoagulant therapy (AC) is recommended by AMI-guidelines. When, despite AC, LV-thrombi lead to embolism, surgical thrombectomy is an option, which is not mentioned or not recommended in AMI-guidelines. Case Presentation: We report a 46-year old female patient with AMI. An 80% stenosis of the proximal left anterior descending coronary artery was treated by a drug-eluting stent. Thrombi within the akinetic LV-apex became mobile despite AC and dual antiplatelet therapy, and a cerebellar stroke occurred. By a transmitral surgical approach with endoscopic assistance the thrombi were completely removed. Postoperative course and 12-months follow-up were uneventful. Conclusions: LV-thrombi should be observed carefully regarding changes in morphology. Surgical thrombectomy of LV-thrombi is a rare treatment option to prevent imminent embolism. Benefits versus risks of surgical removal of LV-thrombi need to be carefully weighted.

Introduction: In patients with cerebral amyloid angiopathy (CAA), intracerebral hemorrhage (ICH) and atrial fibrillation (AF), both antiplatelet and anticoagulant therapy for prevention of embolic stroke increases the risk of recurrent intracerebral hemorrhage. Left atrial appendage closure (LAAC) has, therefore, been suggested as an alternative to antithrombotic therapy in patients with CAA.Case description: A man in his mid-80s suffered from ICH and CAA was diagnosed by magnetic resonance imaging of the brain. He had a history of arterial hypertension, dyslipidemia, monoclonal gammopathy (IgG kappa), and chronic obstructive pulmonary disease. Four months previously, edoxaban 60 mg/d had been prescribed because of permanent AF. Blood pressure at admission was 170/80 mm Hg. The NT-pro-BNP level was 1819 ng/L (reference value: < 486 ng/L). The electrocardiogram showed AF. Echocardiography showed an enlarged left atrium, left ventricular wall thickening, good systolic function and diastolic dysfunction. Edoxaban was stopped and the ICH resolved within 16 days. Interventional LAAC was considered but eventually not performed because of the following reasons: 1. Postinterventional antiplatelet therapy to prevent device-associated thrombus formation would expose him to the risk of recurrent ICH. 2. Aggravation of heart failure may occur due to the missing hemodynamic and endocrine properties of the left atrial appendage. Thus, optimization of antihypertensive therapy without any antiplatelet or anticoagulant therapy was recommended. Thirteen months after ICH, no further hemorrhagic or ischemic events had occurred. Conclusion: In view of the lack of randomized clinical trials in patients with CAA, ICH and AF, neither LAAC nor anticoagulant nor antiplatelet therapy but a healthy lifestyle with a blood-pressure target of < 120/80 mmHg should be recommended to prevent recurrent ICH.