For patients with atrial fibrillation, Warfarin reduces stroke by 68%

Annual stroke rate reduced from 4.5%  to 1.4% per year

There is a tendency for cardioembolic stroke to undergo hemorrhagic transformation  

Best time to start Warfarin after stroke is not clear

For large stroke, consider delay anticoagulation for 2 days to 2 weeks

Except: high risk cardiac lesion, such as  

• mechanical heart valve

• established intracardiac thrombus  

• atrial fibrillation w mitral stenosis or congestive heart failure  

Aim for INR between 2 and 3

Patients under 60 year old with long atrial fibrillation without other stroke risk factor do not need Warfarin

The recommendations are primarily based on  

• patient age  

• presence or absence of a history of cardiovascular risk factors  

• TIA/stroke, hypertension, heart failure, diabetes mellitus, clinical coronary artery disease, echocardiographic findings of left atrial enlargement or left ventricular dysfunction  

In the absence of a medical contraindication to anticoagulation  

• Age > 75 years: warfarin  

• Age 65 - 75 years with risk factor: warfarin;   

• Age 65 - 75 years without risk factor: warfarin or aspirin  

• Age < 65 years with risk factor: warfarin  

• Age < 65 years without risk factor: aspirin or observe.  

Risk of intracranial hemorrhage  (pooled analysis)  

• 0.3% vs 0.1% per year in control group  

Risk of intracranial hemorrhage for patient >75 year old  

• 1.8% per year  

Risk of hemorrhage may increase with INR > 3    

Crescendo TIA

Cervical artery dissection

Severe carotid stenosis

Antiphospholipid Antibody Syndrome

Coagulation factor deficiencies

Intracranial venous thrombosis