Our case report presents the clinical management of a 77-year-old female with recurrent acute ischemic stroke (AIS) due to severe intracranial large artery atherosclerosis (LAA), requiring intracranial stenting complicated by new-onset atrial fibrillation (AF). This clinical scenario necessitated the use of triple antithrombotic therapy (TAT) with aspirin, ticagrelor, and apixaban. While guidelines recommend minimizing the duration of TAT or favoring alternative regimens due to bleeding risks, this case highlights the safe application of an extended duration TAT course in a high-risk patient. The patient initially presented with recurrent AIS despite dual antiplatelet therapy (DAPT). Subsequent intracranial stenting and AF diagnosis posed challenges in balancing ischemic and bleeding risks. Multidisciplinary, shared decision-making guided the initiation of TAT. Despite a history of early recurrent strokes and high-risk stenting, no major, life-threatening, or minor bleeding complications were observed during the extended duration of TAT. This case underscores the need for tailored antithrombotic regimens in neurovascular patients with AF and high ischemic risk.