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

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, 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.