[Analysis of the prevalence of anticoagulant therapy in patients with cognitive disorders and cerebral amyloid angiopathy (CAA)]. / Analyse zur Häufigkeit einer gerinnungshemmenden Medikation bei Patientinnen mit kognitiven Störungen und zerebraler Amyloidangiopathie (CAA).

OBJECTIVES: To investigate the prevalence of coincident anticoagulation in patients with cognitive disorders and possible or probable cerebral amyloid angiopathy (CAA) as well as the relationship between the presence of oral anticoagulation and CAA-specific lesion load. MATERIALS AND METHODS: Patients with subjective cognitive decline (SCD), amnestic and non-amnestic mild cognitive impairment (aMCI/naMCI), Alzheimer's disease (AD), mixed dementia (MD) and vascular dementia (VD) who presented to our outpatient dementia clinic between February 2016 and October 2020 were included in this retrospective analysis. Patients underwent cranial magnetic resonance imaging (MRI). MRI data sets were analyzed regarding the presence of CAA-related MRI biomarkers to determine CAA prevalence. Presence of anticoagulant therapy was determined by chart review. RESULTS: Within the study period, 458 patients (209 male, 249 female, mean age 73.2 ± 9.9 years) with SCD (n = 44), naMCI (n = 40), aMCI (n = 182), AD (n = 120), MD (n = 68) and VD (n = 4) were analyzed. A total of 109 patients (23.8%) were diagnosed with possible or probable CAA. CAA prevalence was highest in aMCI (39.4%) and MD (28.4%). Of patients with possible or probable CAA, 30.3% were under platelet aggregation inhibition, 12.8% were treated with novel oral anticoagulants and 3.7% received phenprocoumon treatment. Regarding the whole study cohort, patients under oral anticoagulation showed more cerebral microbleeds (p = 0.047). There was no relationship between oral anticoagulation therapy and the frequency of cortical superficial siderosis (p = 0.634). CONCLUSION: CAA is a frequent phenomenon in older patients with cognitive disorders. Almost half of CAA patients receive anticoagulant therapy. Oral anticoagulation is associated with a higher number of cortical and subcortical microbleeds.

Impact of Quality Standards on Stroke Management and Outcome Requires Appropriately Designed Studies.

How to cite this article: Mehri S, Finsterer J. Impact of Quality Standards on Stroke Management and Outcome Requires Appropriately Designed Studies. Indian J Crit Care Med 2024;28(4):406-407.

Improper monitoring and deviations from physiologic treatment goals in patients with brain injury in the early phases of emergency care.

Severe traumatic brain injury (TBI), out-of-hospital cardiac arrest (OHCA) and intracerebral- and subarachnoid hemorrhage (ICH/SAH) are conditions associated with high mortality and morbidity. The aim of this study was to investigate the feasibility of obtaining continuous physiologic data and to identify possible harmful physiological deviations in these patients, in the early phases of emergency care. Patients with ICH/SAH, OHCA and severe TBI treated by the Physician-staffed Emergency Medical Service (P-EMS) between September and December 2016 were included. Physiological data were obtained from site of injury/illness, during transport, in the emergency department (ED) and until 3 h after admittance to the intensive care unit. Physiological deviations were based on predefined target values within each 5-min interval. 13 patients were included in the study, of which 38% survived. All patients experienced one or more episodes of hypoxia, 38% experienced episodes of hypercapnia and 46% experienced episodes of hypotension. The mean proportion of time without any monitoring in the pre-hospital phase was 29%, 47% and 56% for SpO2, end-tidal CO2 and systolic blood pressure, respectively. For the ED these proportions were 57%, 71% and 56%, respectively. Continuous physiological data was not possible to obtain in this study of critically ill and injured patients with brain injury. The patients had frequent deviations in blood pressure, SpO2 and end tidal CO2-levels, and measurements were frequently missing. There is a potential for improved monitoring as a tool for quality improvement in pre-hospital critical care.

Less dementia and stroke in low-risk patients with atrial fibrillation taking oral anticoagulation.

AIMS: To investigate if patients with atrial fibrillation (AF) without clear indication for oral anticoagulant (OAC) due to perceived low stroke risk may benefit from OAC treatment when also dementia and intracerebral bleeding risks are considered. METHODS AND RESULTS: Retrospective study of cross-matched national registries of all individuals in Sweden with a hospital diagnosis of AF between 2006 and 2014 (n = 456 960). Exclusion was made of patients with a baseline CHA2DS2-VASc score >1, not counting female sex, and of patients with previous diagnosis of dementia or intracranial bleeding. After exclusions, 91 254 patients remained in the study of whom 43% used OAC at baseline. Propensity score matching and falsification endpoints were used. Treatment with OAC was associated with lower risk of dementia after adjustment for death as a competing risk [subhazard ratio (sHR) 0.62 with 95% confidence interval (CI) 0.48-0.81]. Regarding the composite brain protection endpoint, OAC treatment was associated with an overall 12% lower risk (sHR 0.88, CI 0.72-1.00). This apparent benefit was restricted to patients aged >65 years, whereas OAC treatment of patients <60 years of age without risk factors appeared to do more harm than good. CONCLUSION: Low-risk AF patients who take OAC have lower risk of dementia than those who do not use OAC. Patients age >65 years appear to benefit from OAC treatment irrespective of stroke risk score.

Long-Term Follow-Up of Cerebral Amyloid Angiopathy-Associated Intracranial Hemorrhage Reveals a High Prevalence of Atrial Fibrillation.

GOAL: Cerebral amyloid angiopathy (CAA) is the second-most common cause of nontraumatic intracerebral hemorrhages (ICH), surpassed only by uncontrolled hypertension. We characterized the percentage, risk factors, and comorbidities of patients suffering from CAA-related ICH in relation to long-term outcomes. MATERIAL AND METHODS: We performed retrospective analyses and clinical follow-ups of individuals suffering from ICH who were directly admitted to neurosurgery between 2002 and 2016. FINDINGS: Seventy-four of 174 (42%) spontaneous nontraumatic lobar ICH cases leastwise satisfied the modified Boston criteria definition for at least "possible CAA." Females suffered a higher risk of CAA-caused ICH (42 of 74, 56.8%, P= .035). Atrial fibrillation as a major comorbidity was observed in 19 patients (25.7%). Recovery (decrease of modified Rankin scale [mRS]) was highest during hospitalization in the acute clinic. One-year mortality was as follows: 14 of 25 patients (56%) with probable CAA without supporting pathology, 6 of 18, and 8 of 31 patients with supporting pathology and possible CAA, respectively. Only 10 of 74 (13.6%) had favorable long-term outcomes (mRS ≤2). Increasing numbers of lobar hemorrhages, low initial Glasgow Coma Scale, and subarachnoid hemorrhage were significantly associated with poor survivability, whereas statins, antithrombotic agents, an intraventricular hemorrhage, and midline shift played seemingly minor roles. CONCLUSIONS: Symptomatic ICH is a serious stage in CAA progression with high mortality. The high incidence of concurrent atrial fibrillation in these patients may support data on more widespread vascular pathology in CAA.

Evolving patterns of intracranial hemorrhage in advanced therapies in patients with acute pulmonary embolism.

BACKGROUND: Dissecting trends and contributing risk factors for intracranial hemorrhage (ICH) in patients treated for acute pulmonary embolism (PE) may allow for a better patient selection for existing and emerging treatment options. METHODS: The German nationwide inpatient sample was screened for patients admitted due to PE 2005-2020. Hospitalizations were stratified for the occurrence of ICH; risk factors for ICH and temporal trends were investigated. RESULTS: Overall, 816,653 hospitalizations due to acute PE in the period 2005-2020 were analyzed in the study. ICH was reported in 2516 (0.3 %) hospitalizations, and time trend analysis revealed a fluctuating but overall, largely unchanged annual incidence. There was an increase of ICH with age. Patients with ICH had a higher comorbidity burden (Charlson-Comorbidity-Index [CCI], 5.0 [4.0-7.0] vs. 4.0 [2.0-5.0]; P < 0.001), and higher CCI was associated with an OR of 1.26 (95%CI 1.24-1.27) for ICH. Further independent risk factors for ICH were age ≥ 70 years (OR 1.23 [1.12-1.34]), severe (versus low-risk) PE (OR 3.09 [2.84-3.35]), surgery (OR 1.59 [1.47-1.72]), acute kidney injury (OR 3.60 [3.09-4.18]), and ischemic stroke (OR 14.64 [12.61-17.00]). The identified risk factors for ICH varied among different reperfusion treatment groups. As expected, ICH had a substantial impact on case-fatality of PE (OR 6.16 [5.64-6.72]; P < 0.001). CONCLUSIONS: Incidence of ICH in patients hospitalized for acute PE in Germany was overall low and depended on the patients' comorbidity burden. Identifying patients at risk for ICH allows tailored patient selection for the different reperfusion treatments and might prevent ICH.

Postoperative Hematoma Expansion in Patients Undergoing Decompressive Hemicraniectomy for Spontaneous Intracerebral Hemorrhage.

Introduction: The aim of the study was to analyze risk factors for hematoma expansion (HE) in patients undergoing decompressive hemicraniectomy (DC) in patients with elevated intracranial pressure due to spontaneous intracerebral hematoma (ICH). Methods: We retrospectively evaluated 72 patients with spontaneous ICH who underwent DC at our institution. We compared the pre- and postoperative volumes of ICH and divided the patients into two groups: first, patients with postoperative HE > 6 cm3 (group 1), and second, patients without HE (group 2). Additionally, we screened the medical history for anticoagulant and antiplatelet medication (AC/AP), bleeding-related comorbidities, age, admission Glasgow coma scale and laboratory parameters. Results: The rate of AC/AP medication was higher in group 1 versus group 2 (15/16 vs. 5/38, p < 0.00001), and patients were significantly older in group 1 versus group 2 (65.1 ± 16.2 years vs. 54.4 ± 14.3 years, p = 0.02). Furthermore, preoperative laboratory tests showed lower rates of hematocrit (34.1 ± 5.4% vs. 38.1 ± 5.1%, p = 0.01) and hemoglobin (11.5 ± 1.6 g/dL vs. 13.13 ± 1.8 g/dL, p = 0.0028) in group 1 versus group 2. In multivariate analysis, the history of AC/AP medication was the only independent predictor of HE (p < 0.0001, OR 0.015, CI 95% 0.001−0.153). Conclusion: We presented a comprehensive evaluation of risk factors for hematoma epansion by patients undergoing DC due to ICH.

Intracerebral bleeding in donors is associated with reduced short-term to midterm survival of heart transplant recipients.

AIM: The quality of the donor heart is known to have a crucial effect on outcome after heart transplantation (HTx). Although leading to brain death in the end, the initial cause of death of the donor and its potential influences on organ quality are heterogeneous. However, it is still controversial to which extent the donor cause of death is associated with outcome or survival post-HTx. METHODS AND RESULTS: We included all patients undergoing HTx in our centre between September 2010 and June 2021 (n = 218). Recipients were divided in five groups related to their donor cause of death: intracerebral bleeding ('ICB', n = 95, 44%), traumatic brain injury ('trauma', n = 54, 25%), hypoxic brain damage ('hypoxic', n = 34, 16%), cerebrovascular ('vascular', n = 15, 7%), or other cause (n = 20, 9%). Baseline characteristics, perioperative parameters, and survival after 30 and 90 days as well as 5 years after transplantation were collected. RESULTS: Intracerebral bleeding in donors compared with traumatic brain injury is associated with higher probability of need for ECLS post-HTx (35% vs. 19%, P = 0.04) and significantly reduced survival up to 5 years post-HTx (i.e. 1 year survival: 61% vs. 95%, P < 0.0001). Although other conditions also show significant changes in outcome and survival, the effect is strongest for ICB, where survival is also reduced compared with all other causes (1 year: 61% vs. 89%, P < 0.0001). CONCLUSIONS: In this retrospective analysis, donor cause of death is associated with differing outcome and survival after HTx. Intracerebral bleeding hereby shows strongest decline in outcome and survival in comparison with all other causes.

Lobar bleeding with ventricular rupture shortly after first dosage of an mRNA-based SARS-CoV-2 vaccine.

Vaccination against SARS-CoV-2 is beneficial but may be rarely accompanied by side effects. We report a 67yo female who developed visual impairment, dysarthria, confusion, and fatigue a few hours after a first dosage with an mRNA-based SARS-CoV-2 vaccine (Pfizer). Her previous history listed diabetes, arterial hypertension, arterial occlusive disease, a single renal cyst on the left side, smoking, and ischemic stroke 20y earlier. Stroke was complicated by normal pressure hydrocephalus requiring placement of a ventriculo-atrial (VA)-shunt. Cerebral imaging revealed a right-sided intracerebral bleeding with ventricular rupture and correct placement of the VA-shunt. Neurosurgeons decided against surgical treatment. The further course was dominated by prolonged confusion, visual impairment, and disorientation but ultimately only minor deficits. In conclusion, a single patient experienced intracerebral bleeding with ventricular rupture shortly after application of the first jab of an mRNA-based SARS-CoV-2 vaccine. Whether bleeding was causally related to the vaccination or occurred coincidentally, remains speculative.

Incidence of delayed bleeding in patients on antiplatelet therapy after mild traumatic brain injury: a systematic review and meta-analysis.

BACKGROUND: The scientific evidence regarding the risk of delayed intracranial bleeding (DB) after mild traumatic brain injury (MTBI) in patients administered an antiplatelet agent (APA) is scant and incomplete. In addition, no consensus exists on the utility of a routine repeated head computed tomography (CT) scan in these patients. OBJECTIVE: The aim of this study was to evaluate the risk of DB after MTBI in patients administered an APA. METHODS: A systematic review and meta-analysis of prospective and retrospective observational studies enrolling adult patients with MTBI administered an APA and who had a second CT scan performed or a clinical follow-up to detect any DB after a first negative head CT scan were conducted. The primary outcome was the risk of DB in MTBI patients administered an APA. The secondary outcome was the risk of clinically relevant DB (defined as any DB leading to neurosurgical intervention or death). RESULTS: Sixteen studies comprising 2930 patients were included in this meta-analysis. The pooled absolute risk for DB was 0.77% (95% CI 0.23-1.52%), ranging from 0 to 4%, with substantial heterogeneity (I2 = 61%). The pooled incidence of clinically relevant DB was 0.18%. The subgroup of patients on dual antiplatelet therapy (DAPT) had an increased DB risk, compared to the acetylsalicylic acid (ASA)-only patients (2.64% vs. 0.22%; p = 0.04). CONCLUSION: Our systematic review showed a very low risk of DB in MTBI patients on antiplatelet therapy. We believe that such a low rate of DB could not justify routine repeated CT scans in MTBI patients administered a single APA. We speculate that in the case of clinically stable patients, a repeated head CT scan could be useful for select high-risk patients and for patients on DAPT before discharge.

Aphasia seven days after second dose of an mRNA-based SARS-CoV-2 vaccine.

OBJECTIVES: Though rare, neurological side effects of SARS-CoV-2 vaccinations are increasingly reported. Even if the first dosage goes uncomplicated, the second dose may be complicated by severe adverse reactions as in the following case. CASE REPORT: A 52yo male developed sudden-onset reading difficulty and aphasia 7d after the second dose of an mRNA-based SARS-CoV-2 vaccine. He had a previous history of myocardial infarction, arterial hypertension, hyperlipidemia, and nephrolithiasis. Blood pressure was slightly elevated on admission. Blood tests revealed mildly elevated D-dimer, pre-diabetes and hyperuricemia. Cerebral magnetic resonance imaging revealed an intracerebral bleeding (ICB) in the left temporal lobe. Aphasia resolved almost completely within a few days. Blood pressure values were normal throughout hospitalisation. Whether there was a causal relation between the ICB and the vaccination remains speculative but cannot be definitively excluded. CONCLUSIONS: A second dose of a SARS-CoV-2 vaccination may be followed by ICB. Though the pathophysiology of ICB remains unexplained a causal relation between ICB and the vaccination cannot be excluded. Risk factors for ICB should be carefully monitored in patients undergoing SARS-CoV-2 vaccination.

Target arterial PO2 according to the underlying pathology: a mini-review of the available data in mechanically ventilated patients.

There is an ongoing discussion whether hyperoxia, i.e. ventilation with high inspiratory O2 concentrations (FIO2), and the consecutive hyperoxaemia, i.e. supraphysiological arterial O2 tensions (PaO2), have a place during the acute management of circulatory shock. This concept is based on experimental evidence that hyperoxaemia may contribute to the compensation of the imbalance between O2 supply and requirements. However, despite still being common practice, its use is limited due to possible oxygen toxicity resulting from the increased formation of reactive oxygen species (ROS) limits, especially under conditions of ischaemia/reperfusion. Several studies have reported that there is a U-shaped relation between PaO2 and mortality/morbidity in ICU patients. Interestingly, these mostly retrospective studies found that the lowest mortality coincided with PaO2 ~ 150 mmHg during the first 24 h of ICU stay, i.e. supraphysiological PaO2 levels. Most of the recent large-scale retrospective analyses studied general ICU populations, but there are major differences according to the underlying pathology studied as well as whether medical or surgical patients are concerned. Therefore, as far as possible from the data reported, we focus on the need of mechanical ventilation as well as the distinction between the absence or presence of circulatory shock. There seems to be no ideal target PaO2 except for avoiding prolonged exposure (> 24 h) to either hypoxaemia (PaO2 < 55-60 mmHg) or supraphysiological (PaO2 > 100 mmHg). Moreover, the need for mechanical ventilation, absence or presence of circulatory shock and/or the aetiology of tissue dysoxia, i.e. whether it is mainly due to impaired macro- and/or microcirculatory O2 transport and/or disturbed cellular O2 utilization, may determine whether any degree of hyperoxaemia causes deleterious side effects.

Management of bleeding in neuroanesthesia and neurointensive care / Vérzésmegelozés és -kezelés a neuroanesztézia és neurointenzív ellátás során.

Intracranial surgical interventions and spontaneous intracerebral hemorrhages challange neuroanesthesia and neurocritical care. First, the brain is the most sensitive organ to tissue hypoxia in the case of severe intraoperative bleedings and, second, a growing hemorrhage within the closed intracranial space may result in a ciritcal elevation of intracranial pressure resulting in an imminent life danger. The authors summerize the potential treatment strategies during neuroanesthesia and neurocritical care. Perioperative organ-specific optimalization of hemoglobin concentration, thrombocyte count and fibrinogen concentrations are key elements in elective neurosurgical interventions. Prior antithrombotic and anticoagulant treatment may indicate targeted pharmacological optimalization and treatment that should be based on laboratory diagnosis. In intracerebral hemorrhages, treatment strategy should be based on the etiology and laboratory diagnostics and targeted pharmacological treatment is preferable. Orv Hetil. 2020; 161(37): 1574-1578.

Disseminated Multifocal Intracerebral Bleeding Events in Three Coronavirus Disease 2019 Patients on Extracorporeal Membrane Oxygenation As Rescue Therapy.

OBJECTIVES: To describe three coronavirus disease 2019 patients suffering from acute respiratory distress syndrome under venovenous extracorporeal membrane oxygenation therapy and tight anticoagulation monitoring presenting a novel pattern of multifocal brain hemorrhage in various degrees in all cerebral and cerebellar lobes. DESIGN: Clinical observation of three patients. Post mortem examinations. SETTING: Two ICUs at the University Hospital Erlangen. PATIENTS: Three patients (medium age 56.6 yr, two male with hypertension and diabetes, one female with no medical history) developed severe acute respiratory distress syndrome on the basis of a severe acute respiratory syndrome coronavirus 2 infection. All required mechanical ventilation and venovenous extracorporeal membrane oxygenation support. INTERVENTIONS: Clinical observation, CT, data extraction from electronic medical records, and post mortem examinations. MAIN RESULTS: We report on an unusual multifocal bleeding pattern in the white matter in three cases with severe acute respiratory distress syndrome due to coronavirus disease 2019 undergoing venovenous extracorporeal membrane oxygenation therapy. Bleeding pattern with consecutive herniation was found in CT scans as well as in neuropathologic post mortem examinations. Frequency for this unusual brain hemorrhage in coronavirus disease 2019 patients with extracorporeal membrane oxygenation therapy at our hospital is currently 50%, whereas bleeding events in extracorporeal membrane oxygenation patients generally occur at 10-15%. CONCLUSIONS: Multifocality and high frequency of the unusual white matter hemorrhage pattern suggest a coherence to coronavirus disease 2019. Neuropathological analyses showed circumscribed thrombotic cerebrovascular occlusions, which eventually led to microvascular and later on macrovascular disseminated bleeding events. However, signs of cerebrovascular inflammation could not be detected. Polymerase chain reaction analyses of brain tissue or cerebrospinal fluid remained negative. Increased susceptibility for fatal bleeding events should be taken into consideration in terms of systemic anticoagulation strategies in coronavirus disease 2019.

A Paraneoplastic Syndrome to Remember: A Case of Disseminated Intravascular Coagulation in Lung Cancer.

Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by the widespread activation of coagulation. It can present as an acute life-threatening emergency or as a chronic process. Mortality is highly dependent on the reversibility of the aetiology and degree of coagulation impairment, so treatment of the underlying cause is vital. The authors present the case of a 57-year-old man whose inaugural presentation of lung cancer was chronic DIC, characterized by three thrombotic events, followed by acute DIC, culminating in death. Metastatic lung cancer was diagnosed only after death. LEARNING POINTS: Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by systemic intravascular activation of coagulation, originating from and causing damage to the microvasculature, which can present as an acute or chronic condition, manifested by bleeding or thrombotic events.Unexplained thrombotic events should raise suspicion of chronic DIC.Treatment will fail, despite supportive measures, if the cause of the DIC is not identified.

Position paper: ability to drive in cerebrovascular diseases.

The regulations for fitness to drive after a cerebrovascular accident in the German Driving License Regulations (FeV) and the German Evaluation Guidelines for Driving Ability (BGL). are not up to date with the current medical knowledge and not consistent with regulations regarding cardiovascular diseases. This position paper presented by six medical and neuropsychological societies in Germany provides a guideline for the assessment of driving ability after diagnosis of a cerebrovascular disease and addresses three major questions: If there is a functional limitation, how can it be compensated for? What is the risk of sudden loss of control while driving in the future? Are there behavioral or personality changes or cognitive deficiencies interfering with safety while driving? Recommendations for the assessment of driving ability in different cerebrovascular diseases are presented. This article is a translation of the position paper published in Nervenarzt: Marx, P., Hamann, G.F., Busse, O. et al. Nervenarzt 90(4): 388-398.

ADAMTS genes and the risk of cerebral aneurysm.

OBJECTIVE Cerebral aneurysms (CAs) affect 2%-5% of the population, and familial predisposition plays a significant role in CA pathogenesis. Several lines of evidence suggest that genetic variations in matrix metalloproteinase genes (MMP) are involved in the etiopathology of CAs. The authors performed a case-control study to investigate the effect of 4 MMP variants from the ADAMTS family on the pathogenesis of CAs. METHODS To identify susceptible genetic variants, the authors investigated 8 single nucleotide polymorphisms (SNPs) in 4 genes from the ADAMTS family (ADAMTS2, -7, -12, and -13) known to be associated with vascular diseases. The study included 353 patients with CAs and 1055 healthy adults. RESULTS The authors found significant associations between CA susceptibility and genetic variations in 3 members of the ADAMTS family. The largest risk for CA (OR 1.32, p = 0.006) was observed in carriers of the ADAMTS2 variant rs11750568, which has been previously associated with pediatric stroke. Three SNPs under investigation are associated with a protective effect in CA pathogenesis (ADAMTS12 variant rs1364044: OR 0.65, p = 0.0001; and ADAMTS13 variants rs739469 and rs4962153: OR 0.77 and 0.63, p = 0.02 and 0.0006, respectively), while 2 other ADAMTS13 variants may confer a significant risk (rs2301612: OR 1.26, p = 0.011; rs2285489: OR 1.24, p = 0.02). CONCLUSIONS These results suggest that reduced integrity of the endothelial wall, as conferred by ADAMTS variants, together with inflammatory processes and defective vascular remodeling plays an important role in CA pathogenesis, although the mechanism of action remains unknown. The authors' findings may lead to specific screening of at-risk populations in the future.

Coincidence of ischemic stroke and recurrent brain haemorrhage in a patient with Klippel-Trenaunay Syndrome.

Cerebrovascular manifestations in Klippel-Trenaunay Syndrome (KTS) have been reported but are extremely rare. Case reports describe brain embolism in KTS-associated coagulopathy as well as bleeding due to arteriovenous malformations. We describe a 45-year-old patient with KTS and both acute ischemic stroke and repeated cerebral haemorrhage. The underlying aetiology of both events remained undetermined despite extensive diagnostic work-up, including coagulation tests and dynamic MR angiography. It is most likely that both a pathological coagulation and increased vessel fragility comparable to amyloid angiopathy were responsible for the combined brain lesions in this patient. We conclude that KTS is a very rare but relevant aetiology of cerebral ischemia and that anticoagulation treatment in these cases should be carefully considered as the risk of cerebral haemorrhage is probably elevated.