Sarti Cristina, Stolcova Miroslava, Scrima Giulia Domna, Mori Fabio, Failli Ylenia, Accavone Donatella, Biagini Silvia, Rapillo Costanza Maria, Nencini Patrizia, Mattesini Alessio, Di Mario Carlo, Meucci Francesco
NEUROFARBA Department, Neuroscience Section, University of Florence, Florence, Italy.
Stroke Unit, Careggi University Hospital, Florence, Italy.
Front Neurol. 2020 Nov 12;11:592458. doi: 10.3389/fneur.2020.592458. eCollection 2020.
Patients with atrial fibrillation (AF) can experience ischemic stroke despite adequate anticoagulant therapy. The secondary prevention strategy of these so-called "resistant strokes" is empirical. Since about 90% of patients with ischemic stroke due to atrial fibrillation have thrombus in left atrial appendage (LAA) we sought to explore the possibility that resistant stroke could have a LAA morphology resistant to anticoagulants. A 77 years old man affected by AF experienced two cardioembolic ischemic stroke while on anticoagulants. The study of LAA showed a windsock-like morphology in the proximal part while distally the LAA presented a cauliflower morphology with a large amount of pectinate muscles and blood stagnation. The precise characteristics of LAA were properly understood integrating images obtained by cardiac CT, transesophageal echocardiography, and selective angiography. A high risky LAA for thrombus formation was diagnosed and its occlusion (LAAO) as an add-on therapy to anticoagulants was proposed and performed. Six month follow-up was uneventfully. The systematic study of LAA in patients with resistant-stroke could help to identify LAA malignant morphology. The efficacy on stroke recurrence of the combined therapy (anticoagulants plus LAAO) is worthy to be tested in randomized trials.
心房颤动（AF）患者即使接受了充分的抗凝治疗仍可能发生缺血性卒中。对于这些所谓的“难治性卒中”，二级预防策略是经验性的。由于约90%的心房颤动所致缺血性卒中患者左心耳（LAA）内有血栓，我们试图探讨难治性卒中可能存在对抗凝剂有抵抗性的LAA形态的可能性。一名77岁的AF患者在接受抗凝治疗期间发生了两次心源性栓塞性缺血性卒中。LAA研究显示，近端呈风袋样形态，而远端LAA呈菜花状形态，有大量梳状肌且血流淤滞。通过整合心脏CT、经食管超声心动图和选择性血管造影获得的图像，正确了解了LAA的精确特征。诊断出一个形成血栓的高危LAA，并提出并实施了将其闭塞（LAAO）作为抗凝剂的附加治疗。六个月的随访过程顺利。对难治性卒中患者的LAA进行系统研究有助于识别LAA的恶性形态。联合治疗（抗凝剂加LAAO）对卒中复发的疗效值得在随机试验中进行检验。
