Balancing thrombosis and hemorrhage: anticoagulation-free VA-ECMO with a multidisciplinary strategy for cerebellar hemorrhage complicated by takotsubo syndrome.

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, anticoagulation-free venoarterial ECMO (VA-ECMO) was initiated 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.