In uno omnia. anti-thrombotic agents in challenging comorbidities

Background: Recurrent bleedings of cavernous malformations are quite frequent and frightful: survival is especially at risk in patients with brainstem cavernous malformations who cannot benefit from neurosurgical treatments. Nevertheless, pragmatic recommendations to prevent recurrent bleedings are still lacking, raising some questions on the daily clinical management of the above patients. Methods: This study reports the case of a 59 year-old woman presenting with past recurrent bleedings from a brainstem cavernous malformation and with indication to start an anti-thrombotic treatment as a consequence of a developing coronary heart disease. Surprisingly, any suggestion about the usage of otherwise indicated anti-platelet treatment and anti-coagulation in patients with cavernous malformations was found in the literature. Results: The authors faced a therapeutical dilemma with this patient, whose survival would be really at risk because of a 'time bomb in her brainstem'. Conclusions: This experience confirms the lack of clear pragmatic recommendations in the clinical management of these patients, whose treatment still represents a medical challenge.