In acute atrial fibrillation-related ischaemic stroke, the risk of both early recurrent ischaemic stroke 5 and haemorrhagic transformation 13 is highest in the days immediately after the index stroke. However, none of the randomised controlled trials comparing DOACs and VKAs included patients with recent ischaemic stroke associated with atrial fibrillation (within the first few weeks)-presumably because of concerns about the risk of haemorrhagic trans formation of the ischaemic brain tissue or of other intracranial haemorrhage. Cochrane reviews and meta-analyses 11, 12 found that these DOACs have similar efficacy to VKAs in primary and secondary prevention of stroke but are associated with about half the frequency of intracranial haemorrhage. Since 2010, four direct oral anti-coagulants (DOACs ie, apixaban, 7 dabigatran, 8 edoxaban, 9 and rivaroxaban 10) have been approved for use in patients with non-valvular atrial fibrillation. 6 Vitamin K antagonists (VKAs) are still recommended as first-line therapy in patients with atrial fibrillation in many countries, although there is scarce evidence from randomised controlled trials of VKA efficacy in acute ischaemic stroke. 5 A meta-analysis of subgroups of patients with atrial fibrillation from randomised controlled trials using heparins within 48 h of ischaemic stroke did not find a significant reduction in the risk of recurrent ischaemic stroke but did find a significantly increased risk of intracranial haemorrhage. 4 Historical observational data (including data from the control groups of randomised control trials) show that, without anti-coagulation, the risk of early recurrence in the first 14 days after atrial fibrillation-related ischaemic stroke is between about 0в™µ% and 1в™і% per day. Clinicians therefore remain uncertain regarding when to commence DOAC administration after acute ischaemic stroke in patients with atrial fibrillation.Д¬erebral embolism attributable to non-valvular atrial fibrillation accounts for 13вЂ“26% of ischaemic strokes 1вЂ“ 3 this proportion increases with age. However, none of these DOAC trials included patients who had experienced ischaemic stroke recently (within the first few weeks). Randomised controlled trials have subsequently shown that direct oral anticoagulants (DOACs ie, apixaban, dabigatran, edoxaban, and rivaroxaban) are at least as effective as VKAs in primary and secondary prevention of atrial fibrillation-related ischaemic stroke, with around half the risk of intracranial haemorrhage. This assumption, and current treatment guidelines, are based on historical, mostly observational data from patients with ischaemic stroke and atrial fibrillation treated with heparins, heparinoids, or vitamin K antagonists (VKAs) to prevent recurrent ischaemic stroke. Although the risk of early recurrent ischaemic stroke is high in this population, early oral anticoagulation is suspected to increase the risk of potentially harmful intracranial haemorrhage, including haemorrhagic transformation of the infarct. Deciding when to initiate oral anticoagulation in patients with non-valvular atrial fibrillation is a longstanding, common, and unresolved clinical challenge. UCL Queen Square Institute of Neurology, National Hospital for Neurology and Neurosurgery, University College London, London, UK (D J Seiffge MD, D J Werring FRCP) Stroke Center and Department of Neurology, University Hospital, and Department of Clinical Research, University of Basel, Basel, Switzerland (D J Seiffge, S T Engelter MD) Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy (M Paciaroni MD) Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK(J Dawson MD) Dell Medical School, The University of Texas Austin, TX, USA (S Warach PhD, T J Milling PhD) Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Basel, Switzerland (S T Engelter) Department of Neurology, University Hospital Bern and University of Bern, Bern, Switzerland (U Fischer MD) and Department of Neurology, Lund University, Skane University Hospital, Lund, Sweden (B Norrving PhD)ДЄbout 13вЂ“26% of all acute ischaemic strokes are related to non-valvular atrial fibrillation, the most common cardiac arrhythmia globally.

Anti stroke treatment