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. 2025 Dec 26;17(1):9.
doi: 10.1007/s12975-025-01397-3.

Anticoagulation after Hemorrhagic Transformation in Acute Cardioembolic Ischemic Stroke

Hyunsoo Kim  1 , Ye-Eun An  1 , Beom-Seok Seo  1 , Jae-Myung Kim  1 , Kang-Ho Choi  1 , Man-Seok Park  1 , Ji Sung Lee  2 , Joon-Tae Kim  3
Affiliations

Anticoagulation after Hemorrhagic Transformation in Acute Cardioembolic Ischemic Stroke

Hyunsoo Kim et al. Transl Stroke Res. .

Abstract

To assess the association of anticoagulation in patients with cardioembolic acute ischemic stroke (CES) who develop hemorrhagic transformation (HT) and its impact on neuroimaging and functional outcomes. This retrospective study enrolled patients presenting with CES within 48 h at a tertiary stroke center between January 2011 and August 2023. Patients who developed HT during hospitalization and underwent follow-up imaging within 1 week were included, focusing on those with hemorrhagic infarction or parenchymal hematoma type 1. Primary outcomes were HT exacerbation on follow-up imaging and 3-month modified Rankin Scale (mRS) distribution shift, comparing anticoagulation therapy (AC), antiplatelet therapy (APT), and drug discontinuation (DDDD). The safety outcome was the occurrence of symptomatic intracerebral hemorrhage (sICH), which was defined as a hemorrhage concomitant with neurological deterioration. Among 763 patients with HT (age 74.6 ± 8.9 years, 48.1% male), AC was associated with a higher incidence of HT exacerbation compared to APT (adjusted OR 0.48, 95% CI 0.29-0.80, p-value = 0.005). AC associated with a better 3-month mRS compared to both APT (adjusted OR 0.63, 95% CI 0.43-0.92, p-value = 0.017) and DD (adjusted OR 0.38, 95% CI 0.26-0.55, p-value < 0.001). sICH occurred in 5%, with rates of 1.5%, 2.1%, and 11.7% in the AC, APT, and DD groups, respectively (adjusted OR for DD vs. AC: 3.93, 95% CI 1.18-13.16, p-value = 0.026). Anticoagulation in CES patients with HT was associated with a better functional outcome and radiological exacerbation, without a significant increase in sICH risk. These findings suggest that the presence of HT should not necessarily preclude the use of anticoagulation therapy in this patient population. However, our study should be interpreted as hypothesis-generating, and confirmation from future prospective studies is warranted.

Keywords: Acute ischemic stroke; Anticoagulation; Cardioembolism; Hemorrhagic transformation.

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Conflict of interest statement

Declarations. Ethics Approval: The current study was approved by the institutional review board of Chonnam National University Hospital (CNUH-2024-294). Disclosure: Dr. H Kim reports no disclosures. Dr. JT Kim reports no disclosures. Dr. MS Park reports no disclosures. Dr. KH Choi reports no disclosures. Dr. JM Kim reports no disclosures. Dr. YE An reports no disclosures. Dr. BS Seo reports no disclosures. Dr. JS Lee reports no disclosures. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
3-month mRS distribution according to the treatment after HT
Fig. 2
Fig. 2
Associations of the treatment after HT with 3-month vascular outcomes. (A) Stroke recurrence, (B) composite vascular outcome
See this image and copyright information in PMC

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