PROS AND CONS ABOUT THE ADMINISTRATION OF ANTICOAGULANTS IN PATIENTS WITH HEMORRHAGIC STROKE AND VALVULAR PROSTHESIS - CASE REPORT

摘要

The coexistence of hemorrhagic stroke with severe mitral valve disease, corrected by prosthetic valve, leads to problems in case management related to the anticoagulant therapy. A decision on therapeutic line, in such a situation, should take into account the ratio between the advantages/disadvantages in the administration of the anticoagulant, the generating mechanisms of these cardiovascular pathologies and the interference of the anticoagulant with these pathologies, the complications that may arise, of course all based on concrete and specific evolution of the patient. The patient C.I., aged 65, with mitral prosthesis, with chronic heart failure (CHF), New York Heart Association (NYHA) class III, aortic insufficiency, atrial fibrillation (AFI) and high pulse rate, (PR) hypertension (high blood pressure) grade III, with very high cardiovascular risk, Parkinson’s disease stage II, with oral anticoagulant for 2 years, suffering a hemorrhagic stroke (confirmed by CT), resulted with right hemiparesis and vascular coma grade II. In the first 5 days, anticoagulant therapy - low molecular weight heparin (LMWH) is maintained, administered subcutaneously as recommended by the cardiologist, but Glasgow Coma Scale (GCS) = 8 points, stationary clinical course, thus being decided to cease the anticoagulant therapy, after interdisciplinary consultation (cardiologist, neurologist, neurosurgeon, intensive care specialist). In the following 3 weeks, the patient had a favourable evolution, with normalization of laboratory parameters, the occurrence of swallowing and cough reflexes, spontaneous opening of eyes, poor responsiveness to noxious stimuli, normalized thermal curve. Monitoring the size of intraparenchymal hematoma by repeated computed tomography (CT) shows a regression of it, especially after discontinuing anticoagulation treatment but maintaining the important mass effect on ventricular system. Despite the favourable evolution in the 27th day, the general condition worsened, requiring supportive measures. After 24 hours, the patient dies of cardiac arrest, the heart did not respond to resuscitation.