Can antiplatelet therapy be continued in a patient with a new lacunar infarct and chronic microhemorrhages?

Antiplatelet Therapy in Patients with Lacunar Infarct and Chronic Microhemorrhages

Antiplatelet therapy should be continued in patients with lacunar infarct and chronic microhemorrhages as the benefits of stroke prevention outweigh the bleeding risks in most cases. 1

Assessment of Risk-Benefit Profile

When evaluating patients with lacunar infarct and chronic microhemorrhages:

• Consider the patient's baseline risk factors for both recurrent ischemic events and hemorrhagic complications 1
• Evaluate the location, number, and pattern of microhemorrhages (lobar versus deep) 1
• Assess the time since the last hemorrhagic event, as bleeding risk decreases over time 1

Evidence Supporting Antiplatelet Continuation

Ischemic Risk Reduction

• Single antiplatelet therapy provides a 22% relative risk reduction in recurrent stroke compared to placebo in patients with lacunar stroke 2
• Antiplatelet monotherapy is the standard of care for secondary prevention after lacunar stroke 3
• Discontinuing antiplatelet therapy may increase the risk of recurrent ischemic events, particularly in patients with established vascular disease 1

Hemorrhagic Risk Assessment

• The RESTART trial demonstrated that resuming antiplatelet therapy after intracerebral hemorrhage was not associated with an increased risk of recurrent hemorrhage 1
• Current guidelines are permissive regarding antiplatelet use after intracerebral hemorrhage in patients with strong indications for secondary prevention 1
• The risk of bleeding complications should be balanced against the risk of recurrent ischemic events 1

Specific Recommendations

Antiplatelet Selection

• For most patients with lacunar infarct and chronic microhemorrhages:
  • Single antiplatelet therapy (typically aspirin 75-100mg daily) is recommended 1, 2
  • Avoid dual antiplatelet therapy for long-term prevention due to increased bleeding risk 2, 4
  • Consider cilostazol as an alternative agent in high bleeding risk patients due to potentially lower hemorrhagic complications 4

Duration of Therapy

• Continue antiplatelet therapy indefinitely for secondary stroke prevention in patients with lacunar infarct 1, 5
• If temporary discontinuation is needed (e.g., for surgery), restart as soon as hemostasis is achieved 1

Special Considerations

• In patients with extensive microhemorrhages or cerebral amyloid angiopathy, more careful risk-benefit assessment is warranted 1
• For patients with both lacunar infarct and atrial fibrillation requiring anticoagulation:
  • Consider discontinuing antiplatelet therapy after 1-4 weeks of triple therapy 1
  • Prefer clopidogrel as the P2Y12 inhibitor if dual therapy is required 1

Monitoring and Follow-up

• Regular blood pressure monitoring and strict control (<130 mmHg systolic) is crucial in patients with small vessel disease 4
• Periodic neuroimaging may be considered to assess for progression of small vessel disease 5
• Aggressive management of vascular risk factors (diabetes, smoking, hyperlipidemia) is essential 5

Common Pitfalls to Avoid

• Don't automatically discontinue antiplatelet therapy based solely on the presence of microhemorrhages 1
• Avoid dual antiplatelet therapy for long-term prevention in lacunar stroke patients with microhemorrhages due to excessive bleeding risk 2, 4
• Don't overlook the importance of blood pressure control, which is the most consistent risk factor for both ischemic and hemorrhagic small vessel disease 4