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

Abstract

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. Due to the early ischemic recurrence, the decision was made to start anticoagulant therapy despite the presence of ventricular bleeding, and in the absence of contraindications to the use of rivaroxaban [14], it was deemed, at the dose of 15 mg/die, as the optimal strategy due to the patient's reduced glomerular filtration rate (34 ml/min) [5,15]. During the following days, the neurological conditions of the patient improved, with amelioration of both motor and language symptoms. On day 11, a brain CT demonstrated the reabsorption of the intraventricular bleeding without occurrence of new ischemic lesions ( Figure 1G). On discharge, the NIHSS score was 2 and the patient was prescribed home treatment with rivaroxaban. At the 3-month follow-up, the patient had resumed his occupation as farmer and, 1 year after the ischemic stroke, he was still on oral anticoagulation with rivaroxaban 15 mg/die, without reporting hemorrhagic complications. Keywords: DiscussionIn patients with acute cardioembolic stroke, the best time to start anticoagulation remains controversial due to the risk of sHT. As DOACs display a lower intracranial bleeding risk compared to the VKAs, initiation of DOAC therapy has been proposed to follow the 'rule of thumb' of 1-3-6-12: 1 day after a transient ischemic attack (TIA), 3 days after a non-disabling stroke, 6 days after a moderate stroke, and at least 12 days after a severe stroke [14]. However, additional clinical evidence is needed to draw definitive conclusions on this crucial issue.Here, we describe the case of an elderly AF patient with an acute ischemic stroke, who required prompt anticoagulation for early recurrence. As advanced age is not a contraindication to the use of rivaroxaban [14], he was tr...