Abstract Number: Esoc2026ot158 Timing of Anticoagulation After Emergency Endovascular Therapy for Acute Ischemic Stroke With Atrial Fibrillation:a Randomised Controlled Trial

Background and aims The optimal timing of direct oral anticoagulant (DOAC) initiation after acute ischemic stroke with atrial fibrillation (AF) remains uncertain, particularly in patients undergoing endovascular thrombectomy (EVT). Patients treated with EVT typically present with more severe neurological deficits and a higher risk of hemorrhagic complications, whereas delayed initiation of anticoagulation may increase the risk of early embolic recurrence. Most current evidence comes from patients who did not undergo EVT, leaving limited guidance for this high risk subgroup. Methods To compare the safety and efficacy of early versus delayed initiation of DOAC therapy after EVT in patients with large vessel occlusion stroke with AF. Results This is a multicenter, prospective, randomized, open-label trial with blinded outcome assessment. A total of 438 patients with ischemic stroke and atrial fibrillation treated with EVT will be enrolled. Patients will be randomized (1:1) within 72 hours after stroke onset to early initiation (≤4 days) or delayed initiation (5–14 days). Randomization is stratified by NIHSS score, age, sex, study center, and presence of hemorrhagic transformation. Conclusions The primary outcome is a composite of recurrent ischemic stroke, symptomatic intracranial hemorrhage, or all-cause mortality within 90 days. Secondary outcomes include individual components of the primary endpoint, systemic thromboembolism, functional outcome (modified Rankin Scale), health-related quality of life (EQ-5D-5L), and major bleeding events. Conflict of interest