Current UK guidelines recommend delaying anticoagulation for 14 days for disabling stroke (Intercollegiate Stroke Working Party, National Clinical Guideline for Stroke 2016; https://www.strokeaudit.org). A recent observational study (n 1,029) suggested that anticoagulation at 4 to 14 days after cardioembolic stroke had the best outcome but did not have statistical power to determine bene t of earlier anticoagulation.318 Increasing cerebral infarct size is associated with increased risk of both symptomatic hemorrhagic transformation and early recurrent ischemia.313 A systematic review and meta-analysis of 7 randomized trials of UFH, LMWH, or heparinoids (n 4,624) started < 48 h vs aspirin or placebo, found that early anticoagulation was associated with nonsigni cantly reduced recurrent ischemic stroke but with increased intracranial bleeding, and no reduction in death or disability (e-Table 19).310 In contrast, other small studies suggested fewer ischemic strokes without an increase in intracranial bleeding, as well as reduced mortality and disability with early initiation of VKAs (to achieve therapeutic levels by day 7).315,319-321 Observational data suggest that the use of LMWH (as a bridging strategy) together with oral anticoagulation is associated with a higher risk of symptomatic hemorrhage.314,322-324 Observational studies suggest that early (< 14 days) anticoagulation with NOACs might be safe.314,315,318,325 One study reported improved outcomes and no early ICH with NOAC started at a median of 4 days poststroke (n 1,192).326,327 The Pre-Timing of Oral Anticoagulant Therapy in Acute Ischemic Stroke With Atrial Fibrillation: a Prospective Multicenter Registry- based Non-inferiority Randomized Controlled Clinical Trial (TIMING) observational study of 249 patients with AF-associated acute ischemic stroke treated with OAC (< 5 days) reported in-hospital recurrent ischemic stroke in 4.4%, and symptomatic ICH in 3.1%.328 There are no large trials of NOACs including patients within 7 to14 days of a stroke, but 1 small study (Phase 2 Exploratory Clinical Study to Assess the Effects of Xarelto (Rivaroxaban) Versus Warfarin on Ischemia, Bleeding, and Hospital Stay in Acute Cerebral Infarction Patients With Non-valvular Atrial Fibrillation [Triple AXEL]) randomized 195 patients with AF-related acute ischemic stroke to rivaroxaban or warfarin < 5 days and found similar rates of symptomatic/asymptomatic MRI- de ned recurrent ischemia (approximately 30%) or intracranial bleeding (approximately 30%) at 4 weeks, with reduced hospital stay for rivaroxaban.329 Recommendations 34. 