Metoprolol is started and uptitrated for adequate rate control. Therapeutic anticoagulation is deferred, though the patient is able to be started on subQ heparin for DVT prophylaxis. He remains in a-fib.
On day 5 of admission, the patient has an acute onset of word-finding difficulty and right hemiparesis. The stroke team evaluates him and obtains a STAT non-contrast head CT and CTA head/neck. He's developed a distal left M2 occlusion. He goes to NeuroIR and undergoes a successful thrombectomy with TICI 3 reperfusion.
We suspected that this patient actually had paroxysmal rather than just post-operative a-fib. We held off on therapeutic anticoagulation because the risks outweighed the benefits, particularly considering the large surgery he had.
However, he's now developed an acute stroke. The mechanism is likely cardioembolic; could also be intracranial atherosclerosis, if this was identified on his vessel imaging. With his a-fib, though, we really have to worry about the former. This development makes therapeutic anticoagulation more pressing. We can't start it now given the acute stroke. Repeat neuroimaging that'll elucidate the infarct size will help dictate exactly when we'll be able to do so.
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