[Rectal bleeding in a 60-year-old woman under anticoagulation and platelet aggregation inhibition]. / Peranaler Blutabgang bei einer 60-jährigen Patientin unter Antikoagulation und Thrombozytenaggregationshemmung.

CASE REPORT: We report on a woman with lower gastrointestinal bleeding under effective oral anticoagulation with both phenprocoumon and apixaban (with intention to switch to the latter) as well as the antiplatelet agent acetylsalicylic acid for aortic bifurcation kissing stents after stent thrombosis. Our patient presented with weakness and rectal bleeding. Upon examination, she looked anemic and had sinus tachycardia (104 beats per minute). The digital rectal examination revealed bright red blood mixed with clots. We established the diagnosis of lower gastrointestinal bleeding that originated from angiodysplasia in the cecum. The patient was stabilized with fluid resuscitation and transfusion. The bleeding source was treated endoscopically. Phenprocoumon had already been stopped and apixaban was paused immediately. Further intervention regarding coagulation was not needed. CONCLUSIONS: Anticoagulation is an important risk factor for gastrointestinal bleeding. Switching from phenprocoumon (or warfarin) to a non-vitamin K oral anticoagulant (NOAC) should be monitored closely using the international normalized ratio. Apixaban or other NOAC are currently not approved for arterial stent thrombosis and there is no evidence for efficacy. Therefore, off-label use requires careful consideration of the risks and benefits.

[Patent foramen ovale-intervention or pharmaceutical treatment]. / Persistierendes Foramen ovale ­ Intervention oder Arzneitherapie.

BACKGROUND: Approximately 40-50% of patients with cryptogenic stroke have a patent foramen ovale (PFO). A concomitant atrial septal aneurysm aggravates the risk of recurrent stroke. OBJECTIVE: The most important changes regarding the evidence for interventional closure of a PFO in patients with cryptogenic stroke are described. This includes the prerequisites for making a diagnosis and the indications for interventional treatment. The article also provides an overview about platelet aggregation inhibitor treatment with and without oral anticoagulation. CURRENT DATA: The balance between benefits and risks of interventional versus pharmaceutical treatment in patients with cryptogenic stroke and PFO has so far not been sufficiently proven. In 2017 two prospective randomized trials (CLOSE and REDUCE) and the long-term follow-up results of the RESPECT study were published, followed by the results of the DEFENSE-PFO study in 2018. A better assessment of the weighing up of the treatment options can now be made. All four studies showed that the interventional treatment of PFO is superior to pharmaceutical treatment alone for patients with cryptogenic stroke under 60 years of age. CONCLUSION: There was a significant reduction in the incidence of recurrent stroke in patients with interventional PFO closure compared with pharmaceutical treatment. The complication rate of PFO closure is very low and younger patients (<60 years) in particular benefit from PFO closure.

[Catheter-based closure of the left atrial appendage : Stroke prevention in atrial fibrillation]. / Der katheterbasierte Verschluss des linken Vorhofohrs : Schlaganfallprävention bei Vorhofflimmern.

In patients with nonvalvular atrial fibrillation, >90 % of thrombi are detected in the left atrial appendage (LAA). In particular these observations have resulted in the development of catheter-based LAA closure as an approach for stroke prevention in patients with nonvalvular atrial fibrillation in recent years. A preliminary randomized trial provided promising data with respect to efficacy and safety of this approach as compared to anticoagulation with warfarin. The safety of the procedure has been significantly improved in recent years due to procedural experience and refinement of implanted devices. In current clinical practice, this approach is particularly used for patients with nonvalvular atrial fibrillation, a significant ischemic risk (CHA2DS2-VASc score ≥2), and a high bleeding risk, i. e., in patients in whom there are relevant concerns with respect to long-term anticoagulation. The present article discusses the data from randomized clinical studies and registries, the present guideline recommendations, and the practical clinical use of LAA closure for stroke prevention.

[Secondary prophylaxis of ischemic stroke]. / Sekundärprophylaxe des ischämischen Schlaganfalls.

The secondary prophylaxis of ischemic stroke provides an enormous therapeutic potential due to the high frequency of recurrent thrombembolic events and the exceptional importance of modifiable cardiovascular risk factors for the individual risk of stroke. In this respect, anti-thrombotic, interventional and surgical treatment options must be selected based on the respective etiology. Furthermore, meticulous optimization of risk factors is essential for effective long-term care. Close interdisciplinary and intersectoral collaboration is crucial, especially in the long-term treatment.

[Acute treatment of intracerebral hemorrhage]. / Akutbehandlung der intrazerebralen Blutung.

BACKGROUND: Intracerebral hemorrhage (ICH) represents one of the most severe forms of stroke with high morbidity and mortality; however, effective treatment options to significantly improve patient outcome do not exist so far. OBJECTIVE: This review article evaluates the most recent developments in acute ICH treatment. MATERIAL AND METHODS: Analysis and interpretation of currently available evidence regarding ICH treatment, focusing on the most important studies from the last 3 years. RESULTS: Hematoma enlargement, perhaps the most important prognostic factor, should be counteracted by aggressive blood pressure management (targeted systolic pressure 140 mm Hg). In cases of ICH under oral anticoagulation, inhibition of coagulation must be immediately antagonized: vitamin K antagonists with prothrombin complex concentrates (PCC), idarucizumab for dabigatran and andexanet if available or high-dose PCC for factor Xa inhibitors. Currently, surgical treatment strategies, both open and minimally invasive, to evacuate the hematoma can currently not be routinely recommended. In patients with intraventricular ICH, treatment with intraventricular fibrinolysis with or without additional lumbar drainage represents a promising treatment option. CONCLUSION: In recent years, several randomized controlled and observational studies have generated robust evidence regarding ICH treatment; however, there is still no single breakthrough intervention, which significantly improves patient functional outcome. Nevertheless, the sum of various, possibly interacting treatment concepts may potentially improve outcome after ICH.