Timing of Antiplatelet Therapy After Hemorrhagic Stroke
Antiplatelet therapy should be initiated only after confirming the absence of intracranial hemorrhage on follow-up imaging, typically waiting at least 24-48 hours after a hemorrhagic stroke. 1, 2
Assessment Before Initiating Antiplatelet Therapy
When considering antiplatelet therapy after a hemorrhagic stroke, follow this algorithm:
Confirm hemorrhage resolution:
- Obtain follow-up brain imaging to ensure hemorrhage has stabilized
- Verify no ongoing bleeding before initiating any antiplatelet agent
Risk stratification:
- Assess the cause of the original hemorrhagic stroke
- Evaluate the patient's risk for both recurrent hemorrhage and ischemic events
- Consider the size and location of the original hemorrhage
Timing Recommendations
The timing of antiplatelet therapy initiation depends on several factors:
For small, stable hemorrhages: Consider initiating antiplatelet therapy after 24-48 hours if follow-up imaging confirms no active bleeding 1
For larger hemorrhages or those at high risk of rebleeding: Delay antiplatelet therapy for at least 7-14 days and reassess with repeat imaging
For patients who received thrombolytic therapy: Delay antiplatelet therapy until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage 1, 2
Antiplatelet Agent Selection
When initiating therapy after confirming hemorrhage resolution:
First-line option: Start with aspirin 81-160 mg daily as a single agent 1
For high-risk TIA or minor ischemic stroke: Consider dual antiplatelet therapy with aspirin plus clopidogrel only after confirming complete hemorrhage resolution and if the ischemic risk significantly outweighs bleeding risk 1, 2
Loading doses: If initiating therapy, consider a loading dose of 160 mg aspirin after confirming absence of hemorrhage 1
Special Considerations
Dysphagia: For patients with swallowing difficulties, aspirin can be administered rectally (325 mg daily) or via enteral tube (80 mg daily) 1
Monitoring: Close monitoring for any signs of recurrent bleeding is essential in the first weeks after initiating antiplatelet therapy
Dual therapy caution: The risk of major hemorrhage is significantly increased with dual antiplatelet therapy (0.9% vs. 0.4% with monotherapy) 1, making this particularly concerning after a hemorrhagic stroke
Common Pitfalls to Avoid
Starting too early: Initiating antiplatelet therapy before confirming hemorrhage resolution can lead to expansion of the hemorrhage
Using dual therapy unnecessarily: Dual antiplatelet therapy carries a higher bleeding risk and should be used selectively after hemorrhagic stroke
Failing to reassess: Always obtain follow-up imaging before initiating antiplatelet therapy after hemorrhagic stroke
Remember that the decision to start antiplatelet therapy after hemorrhagic stroke requires careful consideration of both bleeding and ischemic risks, with the primary goal of optimizing morbidity, mortality, and quality of life outcomes.