Embolic Stroke, Atrial Fibrillation, and Microbleeds

A 73-year-old man presents with an ischemic stroke. Work-up reveals paroxysmal atrial fibrillation (AF), and magnetic resonance imaging (MRI) shows a small cortical infarct and 8 incidental cortical microbleeds.Should the patient be started on oral anticoagulation or aspirin? if oral anticoagulation, which agent (warfarin, dabigatran, apixaban, others)? Hans-Christoph DienerPatients with AF have a high risk of ischemic stroke, which can be dramatically reduced by oral anticoagulation with vitamin K antagonists (VKAs).1 I will look at our patient from different positions. First, the patient has paroxysmal AF. The type of AF (paroxysmal, persistent, or permanent) has only a minor impact on the stroke risk.2 All types of AF respond to oral anticoagulation with VKAs or non–vitamin K oral anticoagulants (NOACs) in a similar way. Therefore, our patient needs to be anticoagulated.Second, the patient’s MRI shows a cortical embolic looking stroke. Therefore, it is likely that the stroke was due to AF. Lacunar strokes, which are treated with antiplatelet therapy, are located in the white matter, basal ganglia or in the brainstem and midbrain. The location and type of infarction makes a hemodynamic stroke due to large vessel disease unlikely. A patient with a severe carotid stenosis and AF would need to undergo carotid endarterectomy.Third, the patient has a small number of cerebral microbleeds. These do not constitute a contraindication to oral anticoagulation. Microbleeds are key markers of cerebral small vessel disease.3 In a retrospective analysis, Horstmann et al4 analyzed data from a prospectively recruiting stroke registry in patients with AF; 785 patients with ischemic stroke or transient ischemic attack with brain MRI including susceptibility weighted imaging were consecutively enrolled during a 3-year period. At least 1 …