Anticoagulation versus Antiplatelet Therapy in COVID-19–Related Stroke: Navigating Clinical Dilemmas in a Critically Ill Cirrhotic Patient — A case report

Purpose: To illustrate the treatment dilemma when Coronavirus disease 2019 (COVID‑19)–related thrombo‑inflammatory stroke occurs in a patient with cirrhosis and to highlight a mechanism‑guided framework for choosing between antiplatelet and anticoagulant therapy. Case report: A 75‑year‑old man with alcoholic cirrhosis and oesophageal varices was hospitalised for severe COVID‑19 pneumonia. Because his D‑dimer exceeded 3 000 ng/mL, prophylactic low‑molecular‑weight heparin (LMWH) was started. On day 4 he developed an acute right middle cerebral artery M2 occlusion (Alberta Stroke Program Early CT Score, ASPECTS 4); reperfusion therapy was contraindicated. A multidisciplinary team opted to continue LMWH and withhold antiplatelet agents, reasoning that thrombo‑inflammation—not atherosclerosis—was the likely mechanism and that variceal bleeding risk was high. Acute kidney injury emerged on day 6, but careful monitoring showed neither haemorrhage nor stroke progression. The patient later died from respiratory failure unrelated to the stroke. Conclusion: In COVID‑19 stroke with cirrhosis, guideline antiplatelet therapy may not fit the underlying biology. Treatment should be mechanism‑guided, biomarker‑informed, and adjusted to individual bleeding risk. keywords: COVID-19, ischemic stroke, antithrombotic therapy