Difficult situations in anticoagulation after stroke: between Scylla and Charybdis

PURPOSE OF REVIEW: A significant proportion of stroke patients is treated with anticoagulants for secondary stroke prevention. Often, in such patients, stroke physicians are required to make difficult clinical decisions when confronted with the dilemma to choose between the risk of thromboembolism and the risk of bleeding. This article focuses on three common anticoagulant-related situations, where the stroke physician needs to find the delicate balance between the two risks.

RECENT FINDINGS: Three typical case vignettes are presented and the associated dilemmas are discussed: a patient with an anticoagulant-related intracranial hemorrhage: would you restart anticoagulation?, an anticoagulated patient with a previous stroke because of atrial fibrillation is scheduled for an elective polyp removal: how would you handle anticoagulation perioperatively?, and a patient presents with an ischemic stroke because of atrial fibrillation: how soon would you start anticoagulation for secondary stroke prevention? The article summarizes the related literature and discusses the pros and cons of each choice.

SUMMARY: The available evidence is limited; we need to individualize our approach according to the specific characteristics of our patients, and share the decision process with our patients and their proxies, taking strongly into consideration their values and preferences.