From the Research
After a thrombectomy for cerebrovascular accident (CVA) occlusion, anticoagulation is typically held for 24-48 hours, though this timing may vary based on individual patient factors, as supported by studies such as 1. The decision to restart anticoagulation should be guided by post-procedure imaging to confirm absence of hemorrhagic transformation. For patients with atrial fibrillation or other indications for long-term anticoagulation, warfarin can be restarted 3-5 days post-procedure if imaging shows no hemorrhage, with bridging using low molecular weight heparin (such as enoxaparin 1 mg/kg twice daily) until therapeutic INR is achieved. Direct oral anticoagulants (DOACs) like apixaban (5 mg twice daily) or rivaroxaban (20 mg daily) can be considered 3-7 days post-procedure in appropriate patients, as they have been shown to have a lower risk of bleeding compared to warfarin, as seen in studies such as 2 and 3. The timing balances the risk of recurrent thrombosis against the risk of hemorrhagic transformation. Early anticoagulation increases bleeding risk, while delayed anticoagulation may increase thrombotic risk. The presence of large infarct size, uncontrolled hypertension, or hemorrhagic transformation on follow-up imaging should prompt longer delays in restarting anticoagulation. Some studies, such as 4, have shown that DOACs like apixaban have a lower rate of stroke and psychiatric illness compared to traditional anticoagulants like acenocumarol, which supports their use in this context. Additionally, a study such as 5 found that IV thrombolysis before endovascular thrombectomy is associated with better outcomes, but this does not directly inform the decision on when to restart anticoagulation. Overall, the choice of anticoagulant and the timing of its restart should be individualized based on the patient's specific risk factors and clinical presentation.