Case scenarios describing patients with acute ischemic stroke (AIS) of varying severity and hemorrhagic transformation (HT) incidence due to non-valvular paroxysmal atrial fibrillation (PAF) were presented to all US board-certified stroke neurologists in an internet-based questionnaire. Questions assessed timing and choice of anticoagulation for secondary stroke prevention, factors prompting earlier anticoagulation, reasons for specific anticoagulant choice and alternatives to anticoagulation in ineligible patients. Open-ended comments were solicited.

Responses were available from 238 of 1239 surveyed. In patients with small AIS <1/3 MCA territory without HT, only 24% would start anticoagulation within 48 hours from stroke onset, although 80% anticoagulated by 7 days. With increased stroke severity >1/2 MCA territory, fewer (29%) chose to anticoagulate within 7 days, 48% waited 7-14 days, and 23% delayed >14 days. Some requested stability imaging before anticoagulating. Asymptomatic HT did not appreciably affect anticoagulation timing, but with symptomatic HT by SITS-MOST criteria, majority (79%) waited >14 days. Most anticoagulated earlier than initially intended if left atrium/left atrial appendage, acute left ventricular thrombi, or mechanical heart valve were present.  Direct oral anticoagulants (DOACs) were the preferred anticoagulation strategy (62%), and low bleeding risk, affordability/cost and availability of a specific reversal agent were the most common reasons cited (82%, 55%, 42% respectively). Aspirin was preferred by 57% in anticoagulation ineligible.