# A Case of Cerebral Amyloid Angiopathy With Recurrent Hemorrhagic and Ischemic Strokes Under Direct Oral Anticoagulant Therapy for Atrial Fibrillation

## TL;DR

A patient with cerebral amyloid angiopathy and atrial fibrillation had worsening brain bleeds while on anticoagulant therapy, which improved after stopping the medication.

## Contribution

Highlights the potential harm of direct oral anticoagulants in cerebral amyloid angiopathy patients with atrial fibrillation.

## Key findings

- Discontinuation of DOACs led to improvement in micro-infarctions and microbleeds.
- Catheter ablation restored sinus rhythm in the patient with atrial fibrillation.
- DOAC therapy was associated with worsening cerebral hemorrhages in CAA patients.

## Abstract

A 68-year-old male patient was admitted to our clinic with chronic atrial fibrillation (AF) and decreased consciousness. Diffusion-weighted magnetic resonance imaging of the brain revealed areas of high signal intensity, T2* cortical microbleeds (MBs), and cortical superficial siderosis. Cerebral amyloid angiopathy (CAA) with micro-infarction was diagnosed, and direct oral anticoagulant (DOAC) therapy was initiated. Due to increasing MBs and intracerebral hemorrhages, DOAC was discontinued. Subsequently, the micro-infarction and MBs abated, and the patient’s consciousness gradually improved. Catheter ablation was performed for AF, restoring sinus rhythm. DOAC can be harmful for CAA patients with AF linked to cortical hemorrhage. Thus, it is important to discontinue DOACs for micro-infarctions in cases of CAA with AF.