Anticoagulation management of myocardial infarction after deep brain stimulation: a comparison of two cases

Abstract

Deep brain stimulation (DBS) is an established treatment of various diseases, particularly used for idiopathic Parkinson's disease. Frequently, DBS patients are multimorbid and managing them may be challenging, since postoperative complications can become more likely with age. In this article, we present two cases of myocardial infarction after DBS with different therapeutic strategies. Case 1 was anticoagulated with a heparin infusion with a target partial thromboplastine time (PTT) between 50 and 60 s after the myocardial infarction and showed 3 days later, after an initial postoperative inconspicuous cranial computer tomography, an intracerebral haematoma, which was evacuated without explanting the DBS lead. Case 2 was only treated with enoxaparine 40 mg s.c. twice a day after the myocardial infarction without any further complications. Both cases benefited from the DBS with respect to the motor fluctuations, but case 1 continued to suffer from psychomotor slowdown, mild hemiparesis of the left side, visual neglect and a gaze paresis. Unfortunately, there are no established guidelines or therapy recommendations for the management of such patients. An individual therapy regime is necessary for this patient population regarding the bleeding risk, the cardial risk and the symptoms of the patient. Retrospectively, the rejection of the intravenous application of heparin in case 2 seems to be the right decision. But regarding the small number of cases, it remains still an individual therapy. Further experience will help us to develop optimal therapy strategies for this patient population.

Bilateral Pallidal Stimulation Improves Chorea in Antiphospholipid Antibody Syndrome With Oral Anticoagulation

“…Another unique aspect is the fact that our patient was on oral anticoagulation before and after chronic DBS. Usually, oral anticoagulation has been considered a contraindication for DBS, and there is little information in its safety profile . Our report demonstrates that DBS can be considered in an individual patient even with long‐term oral anticoagulation.…”

Anti-Coagulation and Deep Brain Stimulation: Never the Twain Shall Meet?

“…With respect to patients receiving therapeutic anti-coagulation after DBS, a duo of cases reported by Polanski et al [12] show mixed results. The 2 patients in their case report had undergone DBS yet suffered from a myocardial infarction post-operatively, requiring therapeutic anti-coagulation.…”

Deep brain stimulation in patients on chronic antiplatelet or anticoagulation treatment

“…Another study showed that postoperative prophylaxis with or without subcutaneous heparin for venous thromboembolism did not increase the risk for intracranial hemorrhage significantly [ 5 ]. More detailed analysis of the handling of chronic anticoagulation treatment in patients undergoing DBS or with existing DBS systems has been provided mainly in the form of case report or small case series [ 4 , 25 , 31 , 33 , 39 ]. We have reported previously on a patient who received bilateral pallidal DBS for severe chorea due to antiphospholipid antibody syndrome with a need for chronic phenprocoumon treatment.…”

“…The question, however, arises whether an established therapy such as DBS can be denied to these groups of patients. While many neurosurgeons worldwide perform DBS in patients with chronic antiplatelet or anticoagulation treatment, there is very limited published data addressing this problem [ 4 , 25 , 31 , 33 , 36 ]. Furthermore, there are different drugs for antiplatelet or anticoagulation treatment, each with distinctive mechanisms and duration of action.…”