What is the management plan for a 54-year-old male with a recent cerebellar infarct, suspected petechial hemorrhage, and mild ataxia, who is already on Aspirin (acetylsalicylic acid), regarding continuation of Aspirin, potential use of Dapt (dabigatran), and timing and type of repeat neuroimaging, such as Computed Tomography (CT) or Magnetic Resonance Imaging (MRI), and need for Computed Tomography Angiography (CTA) or Magnetic Resonance Angiography (MRA)?

Management of Recent Cerebellar Infarct with Suspected Petechial Hemorrhage

Antiplatelet Management

Continue aspirin therapy in this patient with a recent cerebellar infarct and suspected petechial hemorrhage, as the benefits of stroke prevention outweigh the risk of hemorrhagic transformation in a stable patient with mild symptoms. 1

The management approach for this 54-year-old male with a recent cerebellar infarct (less than half of cerebellar hemisphere) and suspected petechial hemorrhage should be guided by the following considerations:

Aspirin Continuation

• Continue aspirin therapy as the patient is fully conscious, stable, and has only mild ataxia
• The presence of small petechial hemorrhage is not a contraindication to continuing antiplatelet therapy when the patient is neurologically stable 1
• Aspirin at doses of 81-325 mg daily is appropriate for secondary stroke prevention in non-cardioembolic ischemic events 1

Dual Antiplatelet Therapy (DAPT) Considerations

• DAPT is not indicated in this case for several reasons:
  • The patient's stroke occurred 24 hours ago (outside the optimal window for DAPT initiation)
  • DAPT is primarily recommended for minor ischemic stroke (NIHSS ≤3) or high-risk TIA when initiated within 12-24 hours of symptom onset 2
  • The presence of petechial hemorrhage raises concerns about increased bleeding risk with DAPT
  • World Stroke Organization guidelines do not strongly recommend DAPT over single antiplatelet therapy for patients with cerebellar infarcts 1

Neuroimaging Recommendations

Timing of Repeat Imaging

• Repeat neuroimaging should be performed at 24-72 hours after initial presentation to:
  • Assess for hemorrhagic transformation
  • Evaluate for progression of infarct size
  • Monitor resolution of petechial hemorrhage

Type of Imaging

• MRI with diffusion-weighted imaging is the preferred modality for follow-up imaging because:
  • MRI is superior to CT for detecting both acute and chronic intracerebral hemorrhage (96% concordance for acute hemorrhage) 3
  • MRI provides better visualization of posterior fossa lesions, particularly important for cerebellar infarcts 4
  • MRI can better characterize the extent of the infarct and any associated hemorrhagic transformation

Need for Vascular Imaging

• CTA or MRA is indicated to evaluate the vertebrobasilar system because:
  • Identifying the underlying etiology is crucial for secondary prevention strategies
  • American Heart Association/American Stroke Association guidelines recommend CTA or MRA rather than ultrasound for evaluation of vertebral arteries in patients with posterior circulation symptoms 1
  • Vascular imaging can detect vertebrobasilar stenosis, dissection, or other pathologies that might require specific management

Additional Management Considerations

• Blood pressure management: Target systolic blood pressure <140 mmHg 1
• Lipid management: High-dose statin therapy is recommended 1
• Physical activity: At least moderate physical activity should be encouraged once stable 1
• Monitor for neurological deterioration, as cerebellar infarcts can lead to edema and obstructive hydrocephalus

Pitfalls and Caveats

• Do not discontinue aspirin based solely on the presence of petechial hemorrhage in a stable patient, as this increases risk of recurrent ischemic events
• Avoid initiating DAPT outside the recommended time window (>24 hours after symptom onset) as this increases bleeding risk without proven benefit
• Do not rely solely on CT for follow-up imaging of posterior fossa lesions, as it has limited sensitivity compared to MRI
• Remember that cerebellar infarcts can deteriorate rapidly due to edema and mass effect, requiring close monitoring even in initially stable patients