What is the management of a patient with a hemorrhagic stroke who is on Plavix (clopidogrel)?

Management of Clopidogrel in Hemorrhagic Stroke

In patients with hemorrhagic stroke who are on clopidogrel (Plavix), clopidogrel should be immediately discontinued to prevent hematoma expansion and worsening neurological outcomes. 1

Acute Management

The presence of clopidogrel in a patient with hemorrhagic stroke significantly increases the risk of:

• Hematoma expansion
• Worsening neurological outcomes
• Increased mortality

Immediate Steps:

1. Discontinue clopidogrel immediately

   • Clopidogrel is contraindicated in the acute phase of hemorrhagic stroke 1
   • The antiplatelet effect persists for 7-10 days due to irreversible platelet inhibition 2

2. Consider platelet transfusion

   • May be beneficial if urgent neurosurgical intervention is needed
   • Most effective if administered within 4 hours of the loading dose or 2 hours of the maintenance dose 2

3. Monitor for hematoma expansion

   • Serial neuroimaging (CT scans) to assess for bleeding progression
   • Close neurological monitoring

Venous Thromboembolism Prophylaxis

For immobilized patients with hemorrhagic stroke:

• Use mechanical prophylaxis (intermittent pneumatic compression devices) rather than pharmacological agents 1
• Avoid elastic compression stockings as they have not shown benefit 3
• Consider prophylactic-dose heparin or LMWH only after bleeding has stabilized (typically 48-72 hours) 3

Resumption of Antithrombotic Therapy

The decision to resume antithrombotic therapy after hemorrhagic stroke requires careful consideration:

1. For patients with compelling indications (e.g., recent coronary stent):

   • Consider resuming antiplatelet therapy after 7-14 days if the bleeding has stabilized
   • Start with aspirin monotherapy (75-100 mg daily) rather than clopidogrel 3

2. For secondary stroke prevention:

   • If antiplatelet therapy is absolutely necessary, aspirin is preferred over clopidogrel after hemorrhagic stroke 3
   • The combination of aspirin and clopidogrel is not recommended after hemorrhagic stroke due to increased bleeding risk 3

Special Considerations

• Patients with dual antiplatelet therapy: If the patient was on both aspirin and clopidogrel, both should be discontinued in the acute phase
• Patients with atrial fibrillation: Oral anticoagulation should be temporarily discontinued; reassess the risk-benefit ratio before resuming 3
• Patients with mechanical heart valves: Consult cardiology for management, as these patients have high thrombotic risk

Common Pitfalls to Avoid

1. Premature resumption of antiplatelet therapy before hemorrhage stabilization
2. Combining antiplatelet agents with anticoagulants without clear indication, which significantly increases bleeding risk 3
3. Failure to address modifiable risk factors for hemorrhagic stroke (hypertension, alcohol use)
4. Assuming all hemorrhagic strokes are the same - management may differ for lobar versus deep hemorrhages

The management of hemorrhagic stroke in patients on clopidogrel requires balancing the risks of continued bleeding against the risks of thrombotic events. The evidence clearly supports immediate discontinuation of clopidogrel in the acute phase, with careful consideration of when and if antiplatelet therapy should be resumed based on individual risk factors and indications.