CHALLENGES IN ANTICOAGULATION THERAPY FOLLOWING ISCHEMIC STROKE IN PATIENTS WITH ATRIAL FIBRILLATION.

Challenges in anticoagulation therapy following ischemic stroke in patients with atrial fibrillation.Patients with ischemic stroke and atrial fibrillation, determining optimal timing of anticoagulation for secondary prevention is of challenge. Current ESC guidelines recommend initiation of anticoagulation in AF patients 1-12 days post stroke, depending on stroke severity. We report a case, whereby a 62 years old patient presented with a left TACI. She had a thrombus in M1of left MCA with NIHSS and ASPECT score of 19 and 9. Thrombolysis followed by Mechanical Thrombectomy (MT) achieved a TICI3 score and improvement in NIHSS to 1. Twenty-four hours post thrombolysis, CT head revealed a left basal ganglia infarct (2.5cm) with Hemorrhagic Transformation (HT1). Decision to anticoagulate on day 6 post stroke was taken.Five days later, the patient suffered a right TACI, with an NIHSS of 17 and thrombus in M1 segment of right MCA. As thrombolysis was contraindicated, MT was repeated and TICI3 flow achieved. NIHSS reduced to 5 with repeat CT confirming a 1.5cm infarct within the right lentiform nucleus. With high risk of further embolic episodes, split dose low molecular weight heparin was initiated to reduce the risk of further embolic stroke. Three days later, NIHSS deteriorated to 19 and CT head confirmed Parenchymal Hemorrhage (PH1). Anticoagulation was stopped and six weeks rehabilitation followed, reducing NIHSS to 4 and MRS to 2. With resolution of the Haemorrhage, oral anticoagulation with Apixaban was resumed. Three months follow up showed NIHSS and MRS of 1.In conclusion, timing of anticoagulation following stroke is always a challenge, as this case highlights.