Early Anticoagulation for Recurrent Ischemic Stroke despite the Presence of Ventricular Bleeding

In the setting of acute cardioembolic stroke, poor evidence exists on the use of anticoagulation early after the event, as well as in the presence of intraventricular bleeding. Moreover, the best timing to start therapy remains controversial for the high risk of hemorrhagic transformation (HT). Here, we describe the case of an 88-year-old man with atrial fibrillation (AF) and an acute ischemic stroke, who experienced early ischemic stroke recurrence and intraventricular bleeding after thrombolysis. Despite intraventricular bleeding and in light of the reduced kidney function, the decision was made to administer rivaroxaban 15 mg/die starting 5 days after the index event. The early use of rivaroxaban 15 mg/die was associated with clinical improvement in the absence of symptomatic HT and radiological worsening of intraventricular bleeding, and the pre-existing bleeding was regularly reabsorbed. Notably, 1 year after the ischemic stroke, the patient was still on oral anticoagulation with rivaroxaban 15 mg/die, without occurrence of hemorrhagic complications. To our knowledge, this is the first evidence of the efficacy and safety of early anticoagulation with rivaroxaban 15 mg/die after an acute ischemic stroke and early stroke recurrence despite the presence of intraventricular bleeding.