# Between a Rock and a Hard Place: Balancing Embolic Stroke and Intracerebral Hemorrhage Risk in Left Atrial Appendage Occlusion

## TL;DR

This paper addresses the challenge of balancing stroke and bleeding risks in atrial fibrillation patients who cannot take anticoagulants, proposing a framework for personalized treatment decisions.

## Contribution

The paper introduces a multidisciplinary decision-making framework integrating clinical and neuroimaging data to guide stroke prevention in high-risk AF patients.

## Key findings

- ICH recurrence risk varies significantly by subtype, with CAA-related hemorrhage having the highest risk.
- Current bleeding risk scores poorly predict ICH due to lack of hemorrhage etiology and neuroimaging features.
- A decision framework is proposed that combines clinical scores, neuroimaging, and hemorrhage phenotype for individualized care.

## Abstract

Patients with atrial fibrillation (AF) who are not candidates for long-term anticoagulation present a complex therapeutic dilemma due to competing risks of cardioembolic stroke and intracerebral hemorrhage (ICH). This challenge is particularly pronounced in neurologically vulnerable individuals, including those with prior ICH, cerebral amyloid angiopathy (CAA), or neuroimaging markers of cerebral small vessel disease (SVD). Left atrial appendage occlusion (LAAO) has emerged as an alternative stroke prevention strategy for patients with contraindications to anticoagulation; however, optimal patient selection and post-procedural antithrombotic management remain uncertain, largely because existing bleeding risk scores inadequately capture ICH risk. Most hemorrhagic risk scores were designed to estimate systemic bleeding and demonstrate limited ability to predict ICH, as they do not incorporate hemorrhage etiology or neuroimaging features. Importantly, ICH recurrence risk varies substantially by subtype, with the highest risk observed in CAA-related hemorrhage, the lowest in hypertensive SVD, and intermediate risk in mixed or secondary etiologies. These distinctions have direct implications for anticoagulation decisions and consideration of LAAO. Finally, we synthesize contemporary evidence on ICH risk stratification, neuroimaging biomarkers, and antithrombotic strategies following LAAO. We propose a multidisciplinary, evidence-based decision-making framework integrating clinical risk scores, neuroimaging findings, and hemorrhage phenotype to support individualized stroke prevention strategies in high-risk patients with AF.