Early Recurrent Large Vessel Occlusion After Hemorrhagic Transformation in Newly Diagnosed Atrial Fibrillation: Challenges in Anticoagulation Timing and Repeat Mechanical Thrombectomy

Abstract

Atrial fibrillation (AF) is a major cause of cardioembolic stroke, and decisions regarding anticoagulation become particularly challenging when hemorrhagic transformation occurs after reperfusion therapy. We report the case of a 76-year-old man who presented with an acute left middle cerebral artery (MCA) occlusion and underwent intravenous thrombolysis followed by successful mechanical thrombectomy. Subsequent imaging demonstrated hemorrhagic transformation of the infarcted area, and newly diagnosed AF was identified as the likely embolic source. Anticoagulation was deferred because of concerns regarding intracranial bleeding. One week later, the patient developed recurrent neurological deficits secondary to a new ipsilateral large vessel occlusion, requiring repeat mechanical thrombectomy. Following radiological stabilization of the hemorrhagic transformation, anticoagulation was initiated without further complications. This case highlights the clinical challenge of balancing the risk of recurrent cardioembolic event against the risk of hemorrhagic progression when determining the timing of anticoagulation after AF-related ischemic stroke. It also demonstrates that repeat mechanical thrombectomy can be an effective treatment option for selected patients with recurrent large vessel occlusion.