Should a patient with a history of hemorrhagic stroke continue aspirin (acetylsalicylic acid) therapy?

Aspirin Should Be Discontinued in Patients with History of Hemorrhagic Stroke

In patients with a history of hemorrhagic stroke, aspirin therapy should be discontinued due to the increased risk of recurrent intracerebral hemorrhage, which outweighs potential benefits for ischemic stroke prevention.

Evidence-Based Rationale

The American College of Chest Physicians (ACCP) guidelines specifically address this clinical scenario with a clear recommendation against antithrombotic therapy in patients with prior intracerebral hemorrhage:

• The ACCP guidelines suggest against the long-term use of antithrombotic therapy for the prevention of ischemic stroke in patients with a history of symptomatic primary intracerebral hemorrhage (Grade 2C recommendation) 1

This recommendation prioritizes patient safety by recognizing that the risk of recurrent hemorrhagic stroke generally outweighs the potential benefit of ischemic stroke prevention in most patients with prior hemorrhagic stroke.

Risk-Benefit Assessment

Risks of Aspirin in Patients with Prior Hemorrhagic Stroke:

• Aspirin increases the risk of hemorrhagic stroke by approximately 12 events per 10,000 persons 2
• Patients with prior hemorrhagic stroke are already at elevated baseline risk for recurrent bleeding
• The mortality rate from hemorrhagic stroke is significantly higher than from ischemic stroke

Limited Benefits in This Population:

• While aspirin is effective for secondary prevention of ischemic stroke 3, this benefit is outweighed by the hemorrhagic risk in patients with prior brain hemorrhage
• The protective effects of aspirin on reducing overall stroke mortality 4 do not specifically apply to patients with prior hemorrhagic stroke

Special Considerations

There are limited exceptions where antithrombotic therapy might be considered despite prior hemorrhagic stroke:

• Patients at relatively low risk of recurrent ICH (e.g., with deep hemorrhages)
• Patients at very high risk (>7% per year) of thromboembolic events, such as those with:
  • Mechanical heart valves
  • CHADS₂ score ≥4 points 1

In these exceptional cases, the decision requires careful individualized risk assessment, neuroimaging to evaluate for underlying vascular abnormalities, and consideration of alternative approaches to stroke prevention.

Clinical Decision Algorithm

1. Confirm the diagnosis of prior hemorrhagic stroke with neuroimaging
2. Assess the patient's risk factors for recurrent hemorrhage:
   • Location of prior hemorrhage (lobar vs. deep)
   • Presence of cerebral amyloid angiopathy
   • Uncontrolled hypertension
   • Age
3. Evaluate the patient's risk for thromboembolic events:
   • Presence of mechanical heart valve
   • Atrial fibrillation with high CHADS₂ score (≥4)
   • Recent ischemic stroke despite no antiplatelet therapy
4. For most patients with prior hemorrhagic stroke:
   • Discontinue aspirin therapy
   • Focus on controlling modifiable risk factors (hypertension, smoking, alcohol)
5. For the rare patient with very high thromboembolic risk:
   • Consider neurology/cardiology consultation for alternative strategies
   • If antiplatelet therapy is deemed necessary, use the lowest effective dose

Pitfalls to Avoid

• Don't continue aspirin "just to be safe" - in patients with prior hemorrhagic stroke, this approach increases rather than decreases risk
• Don't substitute other antiplatelet agents (clopidogrel, etc.) without recognizing they carry similar bleeding risks
• Don't overlook the importance of blood pressure control as the primary strategy for preventing recurrent hemorrhagic stroke
• Don't fail to distinguish between different types of hemorrhagic stroke (subarachnoid vs. intracerebral) as management may differ

In conclusion, while aspirin has established benefits for ischemic stroke prevention, patients with a history of hemorrhagic stroke represent a distinct population in whom aspirin therapy should generally be discontinued to minimize the risk of potentially fatal recurrent brain hemorrhage.