Tarver Micheal Jace, Schmidt Tyler, Koltz Michael T
Division of Neurosurgery, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX 78712, USA.
Brain Sci. 2018 Jan 7;8(1):12. doi: 10.3390/brainsci8010012.
The authors present a unique case of recurrent stroke, discovered to be secondary to hemorrhagic conversion of microemboli from a mechanical aortic valve despite anticoagulation with Coumadin. The complexity of this case was magnified by the patient's young age, a mechanical heart valve (MHV), and a need for anticoagulation to maintain MHV patency in a setting of potentially life-threatening intracranial hemorrhage. Anticoagulant and antiplatelet therapy are risk factors for hemorrhagic conversion post-cerebral ischemia; however, the pathophysiology underlying endothelial cell dysfunction causing red blood cell extravasation is an active area of basic and clinical research. The need for randomized clinical trials to aid in the creation of standardized treatment protocol continues to go unmet. Consequently, there is marked variation in therapeutic approaches to treating intracranial hemorrhage in patients with an MHV. Unfortunately, patients with an MHV are considered at high thromboembolic (TE) risk, and these patients are often excluded from clinical trials of acute stroke due to their increased TE potential. The authors feel this case represents an example of endothelial dysfunction secondary to microthrombotic events originating from an MHV, which caused ischemic stroke with hemorrhagic conversion complicated by the need for anticoagulation for an MHV. This case offers a definitive treatment algorithm for a complex clinical dilemma.
作者报告了一例独特的复发性中风病例，尽管患者使用香豆素进行抗凝治疗，但发现中风继发于机械主动脉瓣微栓子的出血性转化。患者年轻、植入机械心脏瓣膜（MHV）以及在存在潜在危及生命的颅内出血情况下需要抗凝以维持MHV通畅，使该病例的复杂性进一步增加。抗凝和抗血小板治疗是脑缺血后出血性转化的危险因素；然而，导致红细胞外渗的内皮细胞功能障碍的病理生理学是基础和临床研究的一个活跃领域。开展随机临床试验以帮助制定标准化治疗方案的需求仍未得到满足。因此，治疗有MHV的患者颅内出血的治疗方法存在显著差异。不幸的是，有MHV的患者被认为具有高血栓栓塞（TE）风险，并且由于其TE风险增加，这些患者通常被排除在急性中风的临床试验之外。作者认为该病例代表了一种内皮功能障碍，其继发于源自MHV的微血栓形成事件，导致缺血性中风伴出血性转化，并因MHV需要抗凝治疗而变得复杂。该病例为一个复杂的临床困境提供了明确的治疗算法。
