Anticoagulation after Hemorrhagic Transformation in Acute Cardioembolic Ischemic Stroke

Area of Science:

• Neurology
• Cardiology
• Radiology

Background:

• Cardioembolic stroke (CES) patients are at risk of hemorrhagic transformation (HT).
• The role of anticoagulation (AC) in CES patients with HT is debated.
• Optimal management strategies for CES with HT require further investigation.

Purpose of the Study:

• To assess the association of anticoagulation therapy with neuroimaging and functional outcomes in CES patients who develop hemorrhagic transformation (HT).
• To compare the impact of anticoagulation therapy (AC), antiplatelet therapy (APT), and drug discontinuation (DD) on HT exacerbation and functional recovery.
• To evaluate the safety of AC in this patient population, specifically the risk of symptomatic intracerebral hemorrhage (sICH).

Main Methods:

• Retrospective study of 763 patients with CES and HT admitted between January 2011 and August 2023.
• Included patients with hemorrhagic infarction or parenchymal hematoma type 1 and follow-up imaging within one week.
• Compared outcomes (HT exacerbation, 3-month mRS, sICH) across AC, APT, and DD groups using adjusted analyses.

Main Results:

• Anticoagulation was associated with a lower incidence of HT exacerbation compared to antiplatelet therapy (adjusted OR 0.48).
• AC was linked to better 3-month functional outcomes (mRS) compared to both APT (adjusted OR 0.63) and drug discontinuation (adjusted OR 0.38).
• Symptomatic intracerebral hemorrhage occurred in 5% of patients, with lower rates in AC (1.5%) and APT (2.1%) groups compared to drug discontinuation (11.7%).

Conclusions:

• Anticoagulation therapy in CES patients with HT is associated with improved functional outcomes and reduced radiological exacerbation.
• The risk of symptomatic intracerebral hemorrhage does not appear to be significantly increased with anticoagulation in this context.
• These findings suggest that hemorrhagic transformation should not automatically preclude anticoagulation therapy in CES patients, warranting further prospective investigation.