Ischemic stroke

Anticoagulant therapy in acute stroke

  • in general, immediate anticoagulant therapy is not recommended for patients with acute stroke (AHA/ASA 2019 III/A)
    • heparin and low molecular weight heparins (LMWH) in the acute stage either do not reduce the risk of early stroke recurrence, or their subtle effect is counteracted by a higher incidence of hemorrhage ( FISS-tris) [Wong, 2007]
    • this is also true in patients with AFib (IST trial) [Saxena, 2001]
    • the risk of bleeding is highest:
      • in the first 10-14 days after the stroke
      • in large infarcts with severe deficits
      • in patients with poorly compensated hypertension
  • management of an acute stroke patient already receiving anticoagulant therapy is discussed here
  • acute anticoagulation may be considered in the following scenarios (effectiveness was not proven by clinical trials):
    • intracardiac or aortic thrombosis   Aortic thrombus (CTA and echocardiography)
    • thrombotic stenosis or occlusion of the CCA and ICA –  safety and efficacy are unknown (AHA/ASA 2019 IIb/C-LD)Thrombus in the CCA in a patient with polycytemia veraTrombotic ICA occlusion
      • dual antiplatelet therapy may be an alternative to anticoagulation in this case
    • TIA patients with AFib
  • how to proceed:
    • studies have shown no significant difference in efficiency between LMWH and heparin; start with

      • HEPARIN (rather without bolus administration)
      • LMWH (CLEXANE, FRAXIPARIN) with target anti-Xa 0.5-1 IU/mL
      • DOAC (in TIA with Afib)
    • then switch to DOAC / warfarin

Initiation of anticoagulant therapy in the subacute stage of stroke

Content available only for logged-in subscribers (registration will be available soon)

LMWH bridging

  • bridging anticoagulation refers to giving a short-acting anticoagulant (usually LMWH) in these situations:
    • initiation of anticoagulant treatment
    • periprocedural bridging  → see separate chapter
Content available only for logged-in subscribers (registration will be available soon)

Intracereberal hemorrhage

  • general risk of ICH recurrence ~2-4%/year (without anticoagulation)
  • risk of ICH recurrence with anticoagulation therapy is increased and depends on the cause of bleeding and the used drug ( DOAC vs. DOAC in reduced dose vs. warfarin)
    • ↑ risk in patients with proven cerebral microbleeds (CMBs) on GRE (in the presumption of amyloid angiopathy ⇒ the risk of ICH is increased 7x)   Cortical cerebral microbleeds and lobar hematomas in patient with cerebral amyloid angiopathy
    • ↑ risk in lobar hematomas (> 4%/year)
    • ↑ risk in patients with apolipoprotein E4 (ApoE4)
  • according to meta-analyses (mainly warfarin trials), the re-introduction of anticoagulation reduces the risk of ischemic stroke without a significant increase in ICH risk (Sembill, 2019) [Murthy, 2017]
  • according to the RETRACE trial (meta-analysis), resumption of anticoagulation therapy improves outcome regardless of hematoma type   RETRACE trial - functional outcome at 1 year, stratified by anticoagulation resumption and intracerebral hemorrhage (ICH) location
Content available only for logged-in subscribers (registration will be available soon)

Perioperative and periprocedural management of anticoagulant therapy

icon-angle icon-bars icon-times