Key result
Neurologists favor early anticoagulation after hemorrhagic transformation ~3-fold more for LV thrombus than AF.
Why the study?
The optimal timing for initiating anticoagulation after ischemic stroke is debated, especially for patients with high-risk embolic sources and hemorrhagic transformation who are often excluded from prior studies.
Do vascular neurologists prefer early anticoagulation for high-risk stroke mechanisms compared to atrial fibrillation?
Cross-Sectional (n=201)
Do vascular neurologists prefer early anticoagulation for high-risk stroke mechanisms compared to atrial fibrillation?
Vascular neurologists favor earlier initiation of anticoagulation for high-risk stroke mechanisms like LV thrombus and antiphospholipid syndrome compared to atrial fibrillation, even in the presence of hemorrhagic transformation.
Answers are grounded in this paper and cite their sources.
Preferences diverge by stroke mechanism; leaves open optimal anticoagulation timing and need for prospective trials.
The optimal timing for initiating anticoagulation following an ischemic stroke remains a debated issue. While several professional societies offer guidelines derived from observational studies and randomized clinical trials in patients with atrial fibrillation, these studies often exclude patients with high-risk embolic sources and hemorrhagic transformation. To address this gap, we conducted a nationwide survey to determine current practice patterns among vascular neurologists. We used the REDCap platform at the University of Chicago to distribute a survey to board-certified vascular neurologists identified through the American Board of Psychiatry and Neurology and the American Academy of Neurology databases. Statistical analyses, including t-tests, chi-squared tests, Mann-Whitney-Wilcoxon tests, and Kruskal-Wallis tests, were performed to evaluate continuous and categorical variables as applicable. Out of 1,556 invited participants, 201 (approximately 13%) responded, with 62% identifying as academic neurologists. Early anticoagulation is defined as within 24 h for ischemic stroke < 1.5 cm, 5 days for one third of MCA territory with hemorrhagic transformation type 1, and 7 days with parenchymal hemorrhage type 2. When compared to atrial fibrillation, vascular neurologists are more likely to initiate early anticoagulation in ischemic stroke with hemorrhagic transformation type 1 when it is caused by LV thrombus (69% vs. 21%, p < 0.001), antiphospholipid syndrome (87% v 21%, p < 0.001), and non-occlusive thrombus (83% vs. 21%, p < 0.001). A similar trend of early anticoagulation was noted in cases of ischemic stroke with parenchymal hemorrhage type 2 caused by LV thrombus (63% vs. 13%, p < 0.001), antiphospholipid syndrome (73% vs. 13%, p < 0.001), and non-occlusive thrombus (71% vs. 13%, p < 0.001) when compared to atrial fibrillation as the underlying cause. This study suggests that vascular neurologists prefer early anticoagulation in high-risk stroke mechanisms as compared to atrial fibrillation.
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Khan et al. (2025) conducted a cross-sectional in Ischemic stroke (n=201). High-risk stroke mechanisms (e.g., left ventricular thrombus) vs. Atrial fibrillation was evaluated on Preference for early anticoagulation in ischemic stroke with hemorrhagic transformation type 1 (p=<0.001). Vascular neurologists were significantly more likely to prefer early anticoagulation for ischemic stroke with hemorrhagic transformation type 1 caused by left ventricular thrombus compared to atrial fibrillation (69% vs. 21%).
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