Practice patterns of vascular neurologists in timing anticoagulation for high risk stroke mechanisms versus atrial fibrillation.

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.