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 phase either do not reduce the risk of early stroke recurrence, or their subtle effect is counteracted by a higher incidence of bleeding ( FISS-tris) [Wong, 2007]
    • this is also true for patients with AFib (IST trial) [Saxena, 2001]
    • the risk of bleeding is highest:
      • during the first 10-14 days after the stroke
      • in large infarcts with severe deficits
      • in patients with poorly compensated hypertension
  • management of the acute stroke patients already receiving anticoagulant therapy is discussed here
  • acute anticoagulation may be considered in the following scenarios (clinical trials have not shown efficacy):
    • 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 setting
    • TIA patients with AFib
  • what to do:
    • studies have shown no significant difference in efficacy between LMWH and heparin; start with

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

Initiation of anticoagulant therapy in the subacute phase of stroke

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LMWH bridging

  • bridging anticoagulation refers to the administration of a short-acting anticoagulant (usually LMWH) in these situations:
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Intracerebral 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 drug used ( DOAC vs. low-dose DOAC vs. warfarin)
    • ↑ risk in patients with proven cerebral microbleeds (CMBs) on GRE (if amyloid angiopathy is suspected ⇒ the risk of ICH is increased 7-fold)   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 reintroduction of anticoagulation reduces the risk of ischemic stroke without significantly increasing the risk of ICH (Sembill, 2019) [Murthy, 2017]
  • according to the RETRACE trial (meta-analysis), resumption of anticoagulation therapy improves outcome regardless of the type of hematoma  RETRACE trial - functional outcome at 1 year, stratified by anticoagulation resumption and intracerebral hemorrhage (ICH) location
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Perioperative and periprocedural management of anticoagulant therapy

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Timing of anticoagulant therapy