Balancing Thrombosis and Hemorrhage: Anticoagulation-Free VA-ECMO with a Multidisciplinary Strategy for Cerebellar Hemorrhage Complicated by Takotsubo Syndrome

Balancing Thrombosis and Hemorrhage: Anticoagulation-Free VA-ECMO with a Multidisciplinary Strategy for Cerebellar Hemorrhage Complicated by Takotsubo Syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Balancing Thrombosis and Hemorrhage: Anticoagulation-Free VA-ECMO with a Multidisciplinary Strategy for Cerebellar Hemorrhage Complicated by Takotsubo Syndrome Xianli Chen, Yalan Qin, Wenqi Huang, Youhua Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6224605/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Aug, 2025 Read the published version in BMC Anesthesiology → Version 1 posted 12 You are reading this latest preprint version Abstract Background: Takotsubo syndrome (TTS) following intracranial hemorrhage, particularly cerebellar hemorrhage is rare. The use of extracorporeal membrane oxygenation (ECMO) in such cases poses significant challenges due to the bleeding-thrombosis paradox. Case Presentation: We report a 19-year-old female with cerebellar hemorrhage and TTS who developed refractory cardiogenic shock. Despite maximal pharmacologic support, venoarterial ECMO (VA-ECMO) was initiated without anticoagulation due to the high risk of intracranial bleeding. ECMO stabilized hemodynamics; however, left femoral artery thrombosis occurred postdecannulation. Multidisciplinary collaboration prioritized cerebral protection, delaying thrombectomy until neurological stabilization. The patient regained consciousness and underwent successful delayed intervention. Conclusion: This first reported case demonstrates the feasibility of anticoagulation-free VA-ECMO in patients with cerebellar hemorrhage with TTS. Multidisciplinary decision-making and staged management are critical for balancing thrombosis and hemorrhage risks. VA-ECMO Takotsubo syndrome Cerebellar hemorrhage Anticoagulation-free Multidisciplinary collaboration Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Takotsubo syndrome (TTS) is an acute reversible heart failure syndrome characterized by transient left ventricular dysfunction triggered by emotional or physical stress. Alternative terms include Takotsubo cardiomyopathy, stress-induced cardiomyopathy, and apical ballooning syndrome[ 1 ]. TTS is often associated with acute neurological injuries. The incidence of TTS following intracranial hemorrhage (ICH) varies across studies, predominantly involving brainstem or Subarachnoid hemorrhages, with reported rates of 5%[ 2 ]. However, cerebellar hemorrhage-induced TTS is exceedingly rare, with fewer than 10 documented cases as of 2025. The use of ECMO in ICH patients remains controversial because of anticoagulation requirements. This case provides novel insights into managing such complex clinical dilemmas. Case Presentation A 19-year-old female (55 kg, 166 cm) with no prior medical history presented with dizziness on December 18, 2024, followed by seizures and cardiac arrest. Return of spontaneous circulation (ROSC) was achieved after 10 minutes of resuscitation. Pink frothy sputum was suctioned via an endotracheal tube. Emergency cranial CT revealed a right cerebellar hemorrhage (4×4×3 cm) with intraventricular and subarachnoid extension (Fig. 1 ). Chest CT revealed bilateral pulmonary infiltrates (Fig. 2 ). ECG demonstrated ST-segment depression in leads II, III, aVF, and V3–V6 (Fig. 3 ). Echocardiography revealed left ventricular dilation and systolic dysfunction (LVEF 19%, end-diastolic diameter 46 mm; Fig. 4 ). Biomarkers included elevated troponin T (0.9 ng/mL; reference: 0–0.014) and NT pro-BNP (19,815.55 pg/mL; reference: 0–450). On December 18, 2024, the patient underwent emergent cerebellar hematoma evacuation and decompressive craniectomy. Intraoperative pulmonary edema and hemodynamic collapse required high-dose norepinephrine (2 μg/kg/min). Postoperatively, refractory cardiogenic shock (Vasoactive-Inotropic Score [VIS] 432) and hypoxemia (P/F ratio <50) persisted despite maximal vasopressor support. VA-ECMO was initiated without anticoagulation on December 19, 2024, resulting in rapid hemodynamic stabilization. The LVEF improved to 35% within 24 hours, and ECMO was successfully weaned after 57 hours. Postdecannulation, left femoral artery thrombosis was detected via Doppler ultrasound and computed tomography angiography(CTA) (Figure 5). Anticoagulation was withheld because of the risk of intracranial bleeding.Thrombectomy was delayed until neurological stabilization was achieved. Heparin was initiated on postoperative day 10 (December 29, 2024). The patient regained consciousness (GCS 14) by postoperative day 20. Delayed percutaneous thrombectomy on January 13, 2025, confirmed patent arterial flow. Cerebral angiography revealed a right posterior inferior cerebellar artery arteriovenous malformation (Figure 6). The patient was transferred to rehabilitation on January 16, 2025, for residual limb weakness. Figure 7 shows the patient’s timeline of the clinical condition. Discussion TTS, typically triggered by sympathetic overactivation, is rarely associated with cerebellar hemorrhage. The use of ECMO for ICH is debated due to anticoagulation-related bleeding risks. This case demonstrates a multidisciplinary approach to managing this dilemma. To our knowledge, this is the first report of cerebellar hemorrhage-induced TTS successfully treated with anticoagulation-free VA-ECMO. The pathophysiology of TTS involves catecholamine toxicity and sympathetic storms [ 3 – 5 ]. In this case, the cerebellar hemorrhage likely compressed the brainstem, triggering sympathetic hyperactivity. The appearance of pink frothy sputum in the early stage and cardiac arrest suggest an acute attack of Takotsubo syndrome (TTS). The occurrence of circulatory collapse after surgery is in line with the surgical "second hit" hypothesis. Currently, no relevant clinical guidelines or consensus exist for treating intracranial hemorrhage complicated by TTS. Treatment mainly hinges on identifying cardiomyopathy and promptly managing primary intracranial hemorrhage. Given the reversible cardiac dysfunction, conservative treatment is often adopted for TTS. This involves managing symptoms such as heart failure or arrhythmia and closely monitoring cardiac function [ 6 – 7 ]. In cases of severe heart failure or cardiogenic shock, mechanical circulatory support may be needed. Johanna's systematic review indicated that extracorporeal membrane oxygenation (ECMO) is the most commonly used mechanical circulatory support method for TTS - induced cardiogenic shock, accounting for 50% of cases[ 8 ]. Although the Extracorporeal Life Support Organization (ELSO) guidelines classify severe neurological injury as a relative contraindication for ECMO [ 9 ], recent studies suggest the feasibility of selecting cases with strict monitoring [ 10 ] [ 11 ], this case suggests that selecting neurocritical patients may benefit from ECMO through meticulous risk-benefit assessment. Currently, no consensus exists on the ECMO initiation timing for intracranial hemorrhage with Takotsubo syndrome (TTS). In this case, a unique point is the conflict between neurosurgery and circulatory support time - windows. TTS emerges in the early stage of cerebellar hemorrhage. After cardiopulmonary arrest resuscitation, circulation and oxygenation remained stable. Therefore, immediate craniotomy for cerebellar hematoma evacuation was chosen to address the primary condition. Owing to the interference of the prone position in cerebellar hematoma evacuation on intraoperative ECMO, postoperative ECMO initiation was reasonable. The main challenge in applying ECMO to intracranial hemorrhage patients is anticoagulation management. Conventional ECMO requires systemic anticoagulation (e.g., heparin) to prevent circuit thrombosis, yet anticoagulation during the acute phase of intracranial hemorrhage may exacerbate bleeding. Olson et al. (2021) reported the feasibility of nonanticoagulated ECMO in high - bleeding - risk patients, with ECMO circuit and patient thrombosis incidences of 13.4% and 9.5%, respectively [ 12 ]. De Paulis (2022) also indicated the viability of low - or nonanticoagulation regimens in patients with bleeding [ 13 ]. In this case, the patient underwent cerebellar hematoma evacuation with an untreated cerebellar arteriovenous malformation, which carried a high risk of rebleeding. Thus, nonanticoagulation throughout ECMO support was reasonable. In this case,a nonanticoagulation strategy was adopted, prioritizing cerebral protection. While circuit thrombosis was avoided, femoral artery thrombosis postdecannulation (incidence 15–20% [ 14 ]) underscores the need for vigilant surveillance. Currently, no unified solution exists for the ECMO anticoagulation dilemma in intracranial hemorrhage patients. Strategies include individualized adjustments of anticoagulation intensity (e.g., low - dose or suspended anticoagulation), the use of ECMO materials with enhanced biocompatibility, and multimodal monitoring (e.g., cranial ultrasound, dynamic coagulation assessment) to balance thrombosis and bleeding risks. The long-term safety of these strategies requires more prospective studies. This case applied the "Neuro - first anticoagulation principle " and early thrombosis detection, balancing intracranial hemorrhage and circulatory support, and offering a reference for similar cases. Another feature of this case is the delayed treatment of arterial thrombosis. Typically, arterial thrombosis demands urgent treatment. However, owing to the risk of intracranial hemorrhage, thrombectomy was postponed and successfully performed after intracranial stabilization, reflecting the "damage control" concept: prioritize life - threatening intracranial lesions and address limb ischemia after bleeding risk reduction.​Sicier-Padilla J et al. suggested delaying invasive procedures (such as cardiac surgery) for patients with intracranial hemorrhage, as early intervention may increase the risk of bleeding. Although some patients can undergo surgery safely within four weeks, individual intracranial stability assessment remains essential.​In this case, lower - limb delayed thrombectomy was also attributable to collateral circulation in the affected limb without obvious ischemic symptoms. Guo Xinbin's research indicated that collateral circulation can partially compensate for ischemia, providing a time window for delayed endovascular treatment [ 15 ].​The multidisciplinary team (MDT) opted for conservative monitoring, avoiding rebleeding risk from interventional procedures, underscoring the importance of MDT decision - making and risk assessment. However, the safety of the delayed thrombectomy strategy in such patients still requires more evidence. Multidisciplinary collaboration (MDT) is pivotal in optimizing care. MDT-driven decisions on ECMO timing, anticoagulation, and delayed thrombectomy underscore its value in complex cases[ 16 – 17 ]. Limitations include the absence of coronary angiography and long-term follow-up data. Conclusion This case demonstrates the feasibility of anticoagulation-free VA-ECMO in patients with cerebellar hemorrhage with TTS. The collaboration of the multidisciplinary team (MDT), staged treatment, and the "neuro - first" clinical decision - making process provides a practical framework for the individualized treatment of similar critically ill patients. In the future, it is necessary to further explore the boundaries of ECMO anticoagulation and the prevention and treatment schemes for thrombosis. Abbreviations ECMO: Extracorporeal membrane oxygenation VA-ECMO: Venoarterial extracorporeal membrane oxygenation TTS: Takotsubo syndrome LVEF: Left ventricular ejection fraction MDT: Multidisciplinary team Declarations Acknowledgements Not applicable. Authors’ contributions Y W: Thesis ideation, revision, review, submission; X C:Thesis conception, data collection and analysis, writing; Y Q, W H: Thesis conception and revision. Funding Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article. Ethics approval and consent to participate Not applicable. Consent for publication Full verbal and written consent has been obtained from the patient for sub mission of this manuscript for publication. Competing interests The authors declare that they have no competing interests. Authors' information 1Department of Critical Care Medicine, Dazu Hospital Affiliated with Chongqing Medical University, Chongqing, China. 2 Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. References Lyon AR, Bossone E, Schneider B, et al. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail . 2016;18(1):8-27. Molnár C, Gál J, Szántó D, Fülöp L, Szegedi A, Siró P, Nagy EV, Lengyel S, Kappelmayer J, Fülesdi B. Takotsubo cardiomyopathy in patients suffering from acute non-traumatic subarachnoid hemorrhage-A single center follow-up study. PLoS One. 2022 May 26;17(5):e0268525. Wittstein IS, Thiemann DR, Lima JAC, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med . 2005;352(6):539-548. Paur H, Wright PT, Sikkel MB, et al. High levels of circulating epinephrine trigger apical cardiodepression in a β2-adrenergic receptor/Gi-dependent manner. Circulation . 2012;126(6):697-706. Ghadri JR, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome. Eur Heart J . 2018;39(22):2032-2046. Yokota H, Sugiura S, Ida Y, Itoh H. Neurogenic stress cardiomyopathy following aneurysmal subarachnoid hemorrhage in a very elderly patient—case report. Neurol Med Chir (Tokyo) . 2011;51(12):842-846. Lampropoulos K, Giannoulis E, Bazoukis G, Tse G, Triantafyllou E. Reversible stress cardiomyopathy secondary to aneurysmal subarachnoid hemorrhage: a case report. J Emerg Med . 2017;53(6):e129-e131. von Mackensen JKR, Zwaans VIT, El Shazly A, et al. Mechanical circulatory support strategies in Takotsubo syndrome with cardiogenic shock: a systematic review. J Clin Med . 2024;13(2):473. Lorusso R, Shekar K, MacLaren G, et al. ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients. ASAIO J . 2021;67(8):827-844. Parker BM, Menaker J, Berry CD, et al. Single center experience with veno-venous extracorporeal membrane oxygenation in patients with traumatic brain injury. Am Surg . 2021;87(6):949-953. Fu KX, Ng BHZ, Chua MHX. A unique case of acute brain hemorrhage with left ventricular systolic failure requiring ECMO. BMC Pediatr . 2019;19(1):278. Olson SR, Murphree CR, Zonies D, et al. Thrombosis and bleeding in extracorporeal membrane oxygenation (ECMO) without anticoagulation: a systematic review. ASAIO J . 2021;67(3):290-296. De Paulis S, Cavaliere F. Anticoagulation management in high bleeding-risk ECMO in adults. Front Cardiovasc Med . 2022;9:884063. Prokupets R, Kannapadi N, Chang H, et al. Management of anticoagulation therapy in ECMO-associated ischemic stroke and intracranial hemorrhage. Innovations (Phila) . 2023;18(1):49-57. Guo XB, Liu S, Guan S. The clinical analysis and treatment strategy of endovascular treatment for cerebral venous sinus thrombosis combined with intracerebral hemorrhage. Sci Rep . 2020;10(1):1-10. Rui Y, Qiu X, Zou J, Xie T, Ma B. Clinical application of multidisciplinary team comanagement in geriatric hip fractures. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi . 2019;33(10):1276-1282. Zasada M, Harris J, Groothuizen J, Aroyewun E, Mendis J. Investigating the efficiency of lung multidisciplinary team meetings—a mixed methods study of eight lung multidisciplinary teams. Cancer Med . 2023;12(5):1-12. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 Aug, 2025 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Revision requested 07 Jul, 2025 Reviews received at journal 04 Jul, 2025 Reviewers agreed at journal 03 Jul, 2025 Reviewers agreed at journal 03 Jul, 2025 Reviews received at journal 03 Jul, 2025 Reviewers agreed at journal 01 Jul, 2025 Reviews received at journal 28 Jun, 2025 Reviewers agreed at journal 28 Jun, 2025 Reviewers invited by journal 29 Mar, 2025 Editor assigned by journal 21 Mar, 2025 Submission checks completed at journal 21 Mar, 2025 First submitted to journal 14 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6224605","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":439925721,"identity":"2d3c65a2-5bcc-4922-b9e3-369f35dec79c","order_by":0,"name":"Xianli Chen","email":"","orcid":"","institution":"Dazu Hospital Affiliated with Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xianli","middleName":"","lastName":"Chen","suffix":""},{"id":439925723,"identity":"f7e463f9-3928-4349-938f-b2838ad32683","order_by":1,"name":"Yalan Qin","email":"","orcid":"","institution":"The Second Affiliated Hospital of Chongqing 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space\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6224605/v1/0d1621ad63fddccc50574dd2.png"},{"id":81147082,"identity":"ebb9fea8-80c4-418d-b37a-87f891eb678b","added_by":"auto","created_at":"2025-04-22 18:24:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":212418,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT shows bilateral pulmonary infiltrates and consolidation\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6224605/v1/abf620010beb7e32085c903d.png"},{"id":81147429,"identity":"598ef0e0-05d7-4c26-b84e-5470215c8767","added_by":"auto","created_at":"2025-04-22 18:32:21","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":576912,"visible":true,"origin":"","legend":"\u003cp\u003eThe electrocardiogram (ECG) shows ST-segment depression in leads II, III, aVF, and V3-V6.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6224605/v1/200c5a2aae8c7757d082c40c.png"},{"id":81147086,"identity":"70ea2b42-55e0-4688-8618-1959c47cf4fb","added_by":"auto","created_at":"2025-04-22 18:24:21","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":330120,"visible":true,"origin":"","legend":"\u003cp\u003eEchocardiography reveals an enlarged left ventricle and systolic dysfunction in the apical and mid-ventricular segments.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6224605/v1/18cea409853d00b46a26e5f9.png"},{"id":81147083,"identity":"4553fb0d-cca0-44e7-ac0c-e7385ed47b59","added_by":"auto","created_at":"2025-04-22 18:24:21","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":140940,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography angiography (CTA) of the lower extremities shows occlusion of the upper and middle segments of the left external iliac artery, common femoral artery, and superficial femoral artery.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-6224605/v1/13f33c275798f795a982eca6.png"},{"id":81147430,"identity":"474bd0ad-aab8-46c3-ba57-12e884e9b4ec","added_by":"auto","created_at":"2025-04-22 18:32:21","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":470979,"visible":true,"origin":"","legend":"\u003cp\u003eDigital subtraction angiography (DSA) of the intracranial arteries reveals an arterioven\u0026nbsp;\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6224605/v1/49340ae72ef4eb97bfbb6b1b.png"},{"id":81147097,"identity":"403e5a07-d63b-453c-a651-8673fb494919","added_by":"auto","created_at":"2025-04-22 18:24:21","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":368157,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline of case progression\u003c/p\u003e","description":"","filename":"floatimage9.png","url":"https://assets-eu.researchsquare.com/files/rs-6224605/v1/1ae53dae349f7550f568c250.png"},{"id":90345060,"identity":"e3586e31-3ddb-4bec-9daf-ff40bdb38eb7","added_by":"auto","created_at":"2025-09-01 16:09:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2860716,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6224605/v1/61d2534f-948b-4896-9b30-975e29d7eeea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Balancing Thrombosis and Hemorrhage: Anticoagulation-Free VA-ECMO with a Multidisciplinary Strategy for Cerebellar Hemorrhage Complicated by Takotsubo Syndrome","fulltext":[{"header":"Background","content":"\u003cp\u003eTakotsubo syndrome (TTS) is an acute reversible heart failure syndrome characterized by transient left ventricular dysfunction triggered by emotional or physical stress. Alternative terms include Takotsubo cardiomyopathy, stress-induced cardiomyopathy, and apical ballooning syndrome[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. TTS is often associated with acute neurological injuries. The incidence of TTS following intracranial hemorrhage (ICH) varies across studies, predominantly involving brainstem or Subarachnoid hemorrhages, with reported rates of 5%[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, cerebellar hemorrhage-induced TTS is exceedingly rare, with fewer than 10 documented cases as of 2025. The use of ECMO in ICH patients remains controversial because of anticoagulation requirements. This case provides novel insights into managing such complex clinical dilemmas.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 19-year-old female (55 kg, 166 cm) with no prior medical history presented with dizziness on December 18, 2024, followed by seizures and cardiac arrest. Return of spontaneous circulation (ROSC) was achieved after 10 minutes of resuscitation. Pink frothy sputum was suctioned via an endotracheal tube. Emergency cranial CT revealed a right cerebellar hemorrhage (4\u0026times;4\u0026times;3 cm) with intraventricular and subarachnoid extension (Fig. \u003cspan\u003e1\u003c/span\u003e). Chest CT revealed bilateral pulmonary infiltrates (Fig. \u003cspan\u003e2\u003c/span\u003e). ECG demonstrated ST-segment depression in leads II, III, aVF, and V3\u0026ndash;V6 (Fig. \u003cspan\u003e3\u003c/span\u003e). Echocardiography revealed left ventricular dilation and systolic dysfunction (LVEF 19%, end-diastolic diameter 46 mm; Fig. \u003cspan\u003e4\u003c/span\u003e). Biomarkers included elevated troponin T (0.9 ng/mL; reference: 0\u0026ndash;0.014) and NT pro-BNP (19,815.55 pg/mL; reference: 0\u0026ndash;450).\u003c/p\u003e\n\u003cp\u003eOn December 18, 2024, the patient underwent emergent cerebellar hematoma evacuation and decompressive craniectomy. Intraoperative pulmonary edema and hemodynamic collapse required high-dose norepinephrine (2 \u0026mu;g/kg/min). Postoperatively, refractory cardiogenic shock (Vasoactive-Inotropic Score [VIS] 432) and hypoxemia (P/F ratio \u0026lt;50) persisted despite maximal vasopressor support. VA-ECMO was initiated without anticoagulation on December 19, 2024, resulting in rapid hemodynamic stabilization. The LVEF improved to 35% within 24 hours, and ECMO was successfully weaned after 57 hours. Postdecannulation, left femoral artery thrombosis was detected via Doppler ultrasound and computed tomography angiography(CTA) (Figure 5). Anticoagulation was withheld because of the risk of intracranial bleeding.Thrombectomy was delayed until neurological stabilization was achieved. Heparin was initiated on postoperative day 10 (December 29, 2024). The patient regained consciousness (GCS 14) by postoperative day 20. Delayed percutaneous thrombectomy on January 13, 2025, confirmed patent arterial flow. Cerebral angiography revealed a right posterior inferior cerebellar artery arteriovenous malformation (Figure 6). The patient was transferred to rehabilitation on January 16, 2025, for residual limb weakness. Figure 7 shows the patient\u0026rsquo;s timeline of the clinical condition.\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003eTTS, typically triggered by sympathetic overactivation, is rarely associated with cerebellar hemorrhage. The use of ECMO for ICH is debated due to anticoagulation-related bleeding risks. This case demonstrates a multidisciplinary approach to managing this dilemma. To our knowledge, this is the first report of cerebellar hemorrhage-induced TTS successfully treated with anticoagulation-free VA-ECMO.\u003c/p\u003e \u003cp\u003eThe pathophysiology of TTS involves catecholamine toxicity and sympathetic storms [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this case, the cerebellar hemorrhage likely compressed the brainstem, triggering sympathetic hyperactivity. The appearance of pink frothy sputum in the early stage and cardiac arrest suggest an acute attack of Takotsubo syndrome (TTS). The occurrence of circulatory collapse after surgery is in line with the surgical \"second hit\" hypothesis. Currently, no relevant clinical guidelines or consensus exist for treating intracranial hemorrhage complicated by TTS. Treatment mainly hinges on identifying cardiomyopathy and promptly managing primary intracranial hemorrhage. Given the reversible cardiac dysfunction, conservative treatment is often adopted for TTS. This involves managing symptoms such as heart failure or arrhythmia and closely monitoring cardiac function [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In cases of severe heart failure or cardiogenic shock, mechanical circulatory support may be needed. Johanna's systematic review indicated that extracorporeal membrane oxygenation (ECMO) is the most commonly used mechanical circulatory support method for TTS - induced cardiogenic shock, accounting for 50% of cases[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the Extracorporeal Life Support Organization (ELSO) guidelines classify severe neurological injury as a relative contraindication for ECMO [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], recent studies suggest the feasibility of selecting cases with strict monitoring [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], this case suggests that selecting neurocritical patients may benefit from ECMO through meticulous risk-benefit assessment. Currently, no consensus exists on the ECMO initiation timing for intracranial hemorrhage with Takotsubo syndrome (TTS). In this case, a unique point is the conflict between neurosurgery and circulatory support time - windows. TTS emerges in the early stage of cerebellar hemorrhage. After cardiopulmonary arrest resuscitation, circulation and oxygenation remained stable. Therefore, immediate craniotomy for cerebellar hematoma evacuation was chosen to address the primary condition. Owing to the interference of the prone position in cerebellar hematoma evacuation on intraoperative ECMO, postoperative ECMO initiation was reasonable.\u003c/p\u003e \u003cp\u003eThe main challenge in applying ECMO to intracranial hemorrhage patients is anticoagulation management. Conventional ECMO requires systemic anticoagulation (e.g., heparin) to prevent circuit thrombosis, yet anticoagulation during the acute phase of intracranial hemorrhage may exacerbate bleeding. Olson et al. (2021) reported the feasibility of nonanticoagulated ECMO in high - bleeding - risk patients, with ECMO circuit and patient thrombosis incidences of 13.4% and 9.5%, respectively [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. De Paulis (2022) also indicated the viability of low - or nonanticoagulation regimens in patients with bleeding [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this case, the patient underwent cerebellar hematoma evacuation with an untreated cerebellar arteriovenous malformation, which carried a high risk of rebleeding. Thus, nonanticoagulation throughout ECMO support was reasonable. In this case,a nonanticoagulation strategy was adopted, prioritizing cerebral protection. While circuit thrombosis was avoided, femoral artery thrombosis postdecannulation (incidence 15\u0026ndash;20% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]) underscores the need for vigilant surveillance. Currently, no unified solution exists for the ECMO anticoagulation dilemma in intracranial hemorrhage patients. Strategies include individualized adjustments of anticoagulation intensity (e.g., low - dose or suspended anticoagulation), the use of ECMO materials with enhanced biocompatibility, and multimodal monitoring (e.g., cranial ultrasound, dynamic coagulation assessment) to balance thrombosis and bleeding risks. The long-term safety of these strategies requires more prospective studies. This case applied the \"Neuro - first anticoagulation principle \" and early thrombosis detection, balancing intracranial hemorrhage and circulatory support, and offering a reference for similar cases.\u003c/p\u003e \u003cp\u003eAnother feature of this case is the delayed treatment of arterial thrombosis. Typically, arterial thrombosis demands urgent treatment. However, owing to the risk of intracranial hemorrhage, thrombectomy was postponed and successfully performed after intracranial stabilization, reflecting the \"damage control\" concept: prioritize life - threatening intracranial lesions and address limb ischemia after bleeding risk reduction.​Sicier-Padilla J et al. suggested delaying invasive procedures (such as cardiac surgery) for patients with intracranial hemorrhage, as early intervention may increase the risk of bleeding. Although some patients can undergo surgery safely within four weeks, individual intracranial stability assessment remains essential.​In this case, lower - limb delayed thrombectomy was also attributable to collateral circulation in the affected limb without obvious ischemic symptoms. Guo Xinbin's research indicated that collateral circulation can partially compensate for ischemia, providing a time window for delayed endovascular treatment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].​The multidisciplinary team (MDT) opted for conservative monitoring, avoiding rebleeding risk from interventional procedures, underscoring the importance of MDT decision - making and risk assessment. However, the safety of the delayed thrombectomy strategy in such patients still requires more evidence.\u003c/p\u003e \u003cp\u003eMultidisciplinary collaboration (MDT) is pivotal in optimizing care. MDT-driven decisions on ECMO timing, anticoagulation, and delayed thrombectomy underscore its value in complex cases[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Limitations include the absence of coronary angiography and long-term follow-up data.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case demonstrates the feasibility of anticoagulation-free VA-ECMO in patients with cerebellar hemorrhage with TTS. The collaboration of the multidisciplinary team (MDT), staged treatment, and the \"neuro - first\" clinical decision - making process provides a practical framework for the individualized treatment of similar critically ill patients. In the future, it is necessary to further explore the boundaries of ECMO anticoagulation and the prevention and treatment schemes for thrombosis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eECMO: Extracorporeal membrane oxygenation\u003c/p\u003e\n\u003cp\u003eVA-ECMO: Venoarterial extracorporeal membrane oxygenation\u003cbr\u003e\u0026nbsp;TTS: Takotsubo syndrome\u003cbr\u003e\u0026nbsp;LVEF: Left ventricular ejection fraction\u003cbr\u003e\u0026nbsp;MDT: Multidisciplinary team\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eY W: Thesis ideation, revision, review, submission; X C:Thesis conception, data collection and analysis, writing; Y Q, W H: Thesis conception and revision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFull verbal and written consent has been obtained from the patient for sub mission of this manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1Department of Critical Care Medicine, Dazu Hospital Affiliated with Chongqing Medical University, Chongqing, China.\u003c/p\u003e\n\u003cp\u003e2 Department of Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLyon AR, Bossone E, Schneider B, et al. Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology. \u003cem\u003eEur J Heart Fail\u003c/em\u003e. 2016;18(1):8-27.\u003c/li\u003e\n\u003cli\u003eMolnár C, Gál J, Szántó D, Fülöp L, Szegedi A, Siró P, Nagy EV, Lengyel S, Kappelmayer J, Fülesdi B. Takotsubo cardiomyopathy in patients suffering from acute non-traumatic subarachnoid hemorrhage-A single center follow-up study. PLoS One. 2022 May 26;17(5):e0268525.\u003c/li\u003e\n\u003cli\u003eWittstein IS, Thiemann DR, Lima JAC, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. \u003cem\u003eN Engl J Med\u003c/em\u003e. 2005;352(6):539-548.\u003c/li\u003e\n\u003cli\u003ePaur H, Wright PT, Sikkel MB, et al. High levels of circulating epinephrine trigger apical cardiodepression in a β2-adrenergic receptor/Gi-dependent manner. \u003cem\u003eCirculation\u003c/em\u003e. 2012;126(6):697-706.\u003c/li\u003e\n\u003cli\u003eGhadri JR, Wittstein IS, Prasad A, et al. International Expert Consensus Document on Takotsubo Syndrome. \u003cem\u003eEur Heart J\u003c/em\u003e. 2018;39(22):2032-2046.\u003c/li\u003e\n\u003cli\u003eYokota H, Sugiura S, Ida Y, Itoh H. Neurogenic stress cardiomyopathy following aneurysmal subarachnoid hemorrhage in a very elderly patient—case report. \u003cem\u003eNeurol Med Chir (Tokyo)\u003c/em\u003e. 2011;51(12):842-846.\u003c/li\u003e\n\u003cli\u003eLampropoulos K, Giannoulis E, Bazoukis G, Tse G, Triantafyllou E. Reversible stress cardiomyopathy secondary to aneurysmal subarachnoid hemorrhage: a case report. \u003cem\u003eJ Emerg Med\u003c/em\u003e. 2017;53(6):e129-e131.\u003c/li\u003e\n\u003cli\u003evon Mackensen JKR, Zwaans VIT, El Shazly A, et al. Mechanical circulatory support strategies in Takotsubo syndrome with cardiogenic shock: a systematic review. \u003cem\u003eJ Clin Med\u003c/em\u003e. 2024;13(2):473.\u003c/li\u003e\n\u003cli\u003eLorusso R, Shekar K, MacLaren G, et al. ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients. \u003cem\u003eASAIO J\u003c/em\u003e. 2021;67(8):827-844.\u003c/li\u003e\n\u003cli\u003eParker BM, Menaker J, Berry CD, et al. Single center experience with veno-venous extracorporeal membrane oxygenation in patients with traumatic brain injury. \u003cem\u003eAm Surg\u003c/em\u003e. 2021;87(6):949-953.\u003c/li\u003e\n\u003cli\u003eFu KX, Ng BHZ, Chua MHX. A unique case of acute brain hemorrhage with left ventricular systolic failure requiring ECMO. \u003cem\u003eBMC Pediatr\u003c/em\u003e. 2019;19(1):278.\u003c/li\u003e\n\u003cli\u003eOlson SR, Murphree CR, Zonies D, et al. Thrombosis and bleeding in extracorporeal membrane oxygenation (ECMO) without anticoagulation: a systematic review. \u003cem\u003eASAIO J\u003c/em\u003e. 2021;67(3):290-296.\u003c/li\u003e\n\u003cli\u003eDe Paulis S, Cavaliere F. Anticoagulation management in high bleeding-risk ECMO in adults. \u003cem\u003eFront Cardiovasc Med\u003c/em\u003e. 2022;9:884063.\u003c/li\u003e\n\u003cli\u003eProkupets R, Kannapadi N, Chang H, et al. Management of anticoagulation therapy in ECMO-associated ischemic stroke and intracranial hemorrhage. \u003cem\u003eInnovations (Phila)\u003c/em\u003e. 2023;18(1):49-57.\u003c/li\u003e\n\u003cli\u003eGuo XB, Liu S, Guan S. The clinical analysis and treatment strategy of endovascular treatment for cerebral venous sinus thrombosis combined with intracerebral hemorrhage. \u003cem\u003eSci Rep\u003c/em\u003e. 2020;10(1):1-10.\u003c/li\u003e\n\u003cli\u003eRui Y, Qiu X, Zou J, Xie T, Ma B. Clinical application of multidisciplinary team comanagement in geriatric hip fractures. \u003cem\u003eZhongguo Xiu Fu Chong Jian Wai Ke Za Zhi\u003c/em\u003e. 2019;33(10):1276-1282.\u003c/li\u003e\n\u003cli\u003eZasada M, Harris J, Groothuizen J, Aroyewun E, Mendis J. Investigating the efficiency of lung multidisciplinary team meetings—a mixed methods study of eight lung multidisciplinary teams. \u003cem\u003eCancer Med\u003c/em\u003e. 2023;12(5):1-12.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"VA-ECMO, Takotsubo syndrome, Cerebellar hemorrhage, Anticoagulation-free, Multidisciplinary collaboration","lastPublishedDoi":"10.21203/rs.3.rs-6224605/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6224605/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eTakotsubo syndrome (TTS) following intracranial hemorrhage, particularly cerebellar hemorrhage is rare. The use of extracorporeal membrane oxygenation (ECMO) in such cases poses significant challenges due to the bleeding-thrombosis paradox.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eWe report a 19-year-old female with cerebellar hemorrhage and TTS who developed refractory cardiogenic shock. Despite maximal pharmacologic support, venoarterial ECMO (VA-ECMO) was initiated without anticoagulation due to the high risk of intracranial bleeding. ECMO stabilized hemodynamics; however, left femoral artery thrombosis occurred postdecannulation. Multidisciplinary collaboration prioritized cerebral protection, delaying thrombectomy until neurological stabilization. The patient regained consciousness and underwent successful delayed intervention.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThis first reported case demonstrates the feasibility of anticoagulation-free VA-ECMO in patients with cerebellar hemorrhage with TTS. Multidisciplinary decision-making and staged management are critical for balancing thrombosis and hemorrhage risks.\u003c/p\u003e","manuscriptTitle":"Balancing Thrombosis and Hemorrhage: Anticoagulation-Free VA-ECMO with a Multidisciplinary Strategy for Cerebellar Hemorrhage Complicated by Takotsubo Syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-22 18:24:16","doi":"10.21203/rs.3.rs-6224605/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-07T06:04:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-04T08:58:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181463434581209334548605464609556788875","date":"2025-07-03T22:00:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74401817163261829323764668419889947914","date":"2025-07-03T19:22:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-03T14:29:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102262307485905756415780696802757527985","date":"2025-07-01T05:00:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-28T09:13:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48452195287442719551440307503959671552","date":"2025-06-28T09:10:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-29T07:09:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-21T04:23:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-21T04:20:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2025-03-14T08:23:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b496a357-4592-43bb-8a9d-08b0d9cd2ba0","owner":[],"postedDate":"April 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T16:05:43+00:00","versionOfRecord":{"articleIdentity":"rs-6224605","link":"https://doi.org/10.1186/s12871-025-03312-7","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2025-08-29 15:58:04","publishedOnDateReadable":"August 29th, 2025"},"versionCreatedAt":"2025-04-22 18:24:16","video":"","vorDoi":"10.1186/s12871-025-03312-7","vorDoiUrl":"https://doi.org/10.1186/s12871-025-03312-7","workflowStages":[]},"version":"v1","identity":"rs-6224605","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6224605","identity":"rs-6224605","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}