Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.

中文翻译：

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心源性卒中抗凝治疗的最新进展，特别是血管内治疗。

心源性卒中是发病的主要原因，复发风险很高，抗凝治疗是大多数患者卒中二级预防的支柱。在常规临床实践中实施血管内治疗使开始抗凝治疗的决定变得复杂，特别是对于早期出血转化的患者，这些患者被认为血肿扩大的风险较高。中风后数天和数周内的晚期出血转化仍然是一种潜在的严重并发症，我们仍然没有任何既定的临床或放射学预测工具。开始治疗的最佳时间很难确定，因为延迟有效的二级预防治疗会使患者面临栓塞复发的风险。因此，临床上可以平衡地定义和个体化开始抗凝治疗的最佳时间点，并结合心源性卒中患者出血性转化和缺血性复发的最低风险。在这篇叙述性综述中，我们将重点介绍并批判性地概述心源性卒中不同亚型的最新观察和随机相关证据，特别关注血管内治疗后开始抗凝治疗。我们将主要提及心源性栓塞的最常见原因非瓣膜性心房颤动，并检查中风急性期之前、期间和之后不久抗凝治疗的可能风险和益处。将简要讨论缺血性卒中后抗凝的其他适应症。我们提供了现有数据的综合，以帮助临床医生根据出血转化的存在和程度以及中风的严重程度，个体化开始口服抗凝药的时间。