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Practice Current: How do you manage patients with intracerebral hemorrhage and atrial fibrillation?

Introduction




Practice Current features anonymous surveys intended to assess real-life practice patterns in scenarios where uncertainty exists. There are no right or wrong answers and we understand that extra-medical factors affect neurologic practice.

Please answer each question based on your REGULAR practice, and not your IDEAL practice. For example, if “option A” would be your ideal choice but you regularly do “option B” due to encountered barriers, then choose “option B”.

Estimated Time: 4 Minutes

A 70-year-old female presents to the emergency department with sudden-onset right-sided weakness. She has a history of ischemic stroke ( presumed cardioembolic secondary to non-valvular atrial fibrillation) for which she is prescribed apixaban. She also has a history of hypertension (CHA2DS2-VASc score 5). On examination, blood pressure is 140/90 mmHg and her Glasgow Coma Scale is 13 (E4V4M5) with aphasia and right-sided hemiparesis.

Non-contrast CT head reveals chronic infarcts and an acute left-sided lobar intracerebral hemorrhage, measuring approximately 10mL, with no mass effect. Electrocardiogram shows atrial fibrillation with rapid ventricular response. Transthoracic echocardiogram was unremarkable. CT head and neck angiogram and other investigations revealed no structural or alternate causes of intracranial hemorrhage. MRI showed no evidence of cerebral microbleeds or superficial siderosis.
1. Would you ever resume oral anticoagulation? *This question is required.
One week later, the patient is stable and ready for discharge to a rehabilitation facility.

When would you resume oral anticoagulation?  *This question is required.
Which oral anticoagulant would you prescribe? (Choose one.) *This question is required.
Would you prescribe an antiplatelet for secondary stroke prevention? *This question is required.
2. After discussing your recommendations with the patient, medication therapy is NOT started. Would you recommend left atrial appendage closure? *This question is required.
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