Presentations

Abstract

Introduction: The management of hemorrhagic stroke in elderly patients with atrial fibrillation (AF) on anticoagulation presents significant challenges, particularly when balancing the risks of anticoagulation with the potential for recurrent ischemic events. This case report examines the clinical course of an 87-year-old woman with persistent AF who suffered a hemorrhagic stroke, highlighting the complexities of decision-making in the resumption of anticoagulation, the role of standardized care protocols, and the importance of clear communication in managing patient and family expectations.

Case Information: We present the case of an 87-year-old female with persistent atrial fibrillation (AF) on warfarin, who suffered a hemorrhagic stroke following administration of dextromethorphan. The patient, with a complex medical history including hypertension, diastolic heart failure, and chronic kidney disease, experienced acute left-sided weakness. Initial evaluation at a community hospital confirmed an intracranial hemorrhage (ICH) with midline shift. Warfarin was reversed using prothrombin complex concentrate and vitamin K, and the patient was transferred to a Neurologic Intensive Care Unit (Neuro ICU). Upon admission, the patient's Glasgow Coma Score (GCS) was 14, and she required nasogastric tube (NGT) placement due to dysphagia. Despite initial stabilization and a transfer to a step-down unit, the patient's GCS declined to 9 by Day 12, with persistent encephalopathy attributed to the global effects of ICH and other chronic conditions. Neurology predicted permanent left-sided motor deficits but expected meaningful recovery in language and cognition. On Day 19, a decline in the patient's condition raised concerns for a new ischemic stroke. Repeat imaging revealed a large middle cerebral artery occlusion with resolving ICH, likely due to cardioembolic stroke from AF off anticoagulation. Re-admission to the Neuro ICU followed, and shared decision-making led to the initiation of Comfort Care. The patient was transferred to inpatient hospice and passed away on Day 23.

Discussion/Clinical Findings: This case underscores the challenges in managing elderly patients with AF who experience ICH, particularly in decisions regarding anticoagulation resumption. The patient's outcome, despite an initially optimistic prognosis, suggests the need for standardized care protocols for ICH management in AF patients, consistent neurologic assessments outside of the Neuro ICU, and the integration of objective scoring systems like the PLAN Score for better prognostication and expectation management.

Conclusion: Proactive, compassionate care and continuous education are vital in improving outcomes for similar patients.