When to start antiplatelet (anti-platelet) therapy, such as aspirin (acetylsalicylic acid) or clopidogrel, after an intracerebral hemorrhage (ICH) in a patient with a history of multiple infarcts?

When to Start Antiplatelet Therapy After Intracerebral Hemorrhage in Patients with Multiple Prior Infarcts

In patients with ICH and a history of multiple infarcts requiring antiplatelet therapy, resumption of antiplatelet monotherapy is reasonable after the hemorrhage has stabilized, typically waiting at least several days from ICH onset, with the optimal timing individualized based on thromboembolic risk versus bleeding risk assessment. 1, 2

Risk Stratification Framework

Before deciding on antiplatelet resumption, you must assess both thromboembolic and hemorrhagic risks:

High Thromboembolic Risk Indicators (>7% per year):

• CHADS₂ score ≥4 points (if atrial fibrillation present) 2
• Recent carotid or coronary stenting (especially within 1-3 months) 2
• Multiple prior infarcts (as in your patient) 1
• Mechanical heart valves 2

High Hemorrhagic Recurrence Risk Indicators:

• Lobar hemorrhage location (higher recurrence risk than deep hemorrhages) 2
• Cerebral amyloid angiopathy (very high bleeding risk) 2
• Multiple microbleeds on MRI 2
• Superficial siderosis 2

Evidence-Based Timing Algorithm

For Patients with Very High Thromboembolic Risk:

Wait at least several days from ICH onset before resuming antiplatelet monotherapy, ensuring the hemorrhage has stabilized on repeat imaging. 1, 2 The RESTART trial recruited patients at a median of 76 days after ICH, though there was no difference in effects before versus after this timepoint. 1

For Patients with Standard Thromboembolic Risk:

Current guidelines from multiple societies (American Heart Association, American College of Chest Physicians, Canadian guidelines) indicate that resuming antiplatelet therapy beyond 24 hours after ICH symptom onset may be reasonable for prevention of thromboembolic events. 1, 2 However, the optimal timing remains uncertain and should be based on careful risk-benefit assessment. 1

Special Timing Considerations for Recent Stenting:

• If carotid stenting within 1-3 months: Continue P2Y12 inhibitor (clopidogrel preferred), consider stopping aspirin if dual therapy was being used. 2
• After standard DAPT duration ends (usually 1-3 months post-stenting): Consider stopping all antiplatelet therapy. 2

Critical Management Principles

Antiplatelet Selection:

Use monotherapy only—never dual antiplatelet therapy after ICH. 1, 2 Dual antiplatelet therapy significantly increases bleeding risk without improving outcomes in this population. 1, 2

Preferred agents for monotherapy:

• Aspirin 75-100 mg daily 1
• Clopidogrel 75 mg daily 1
• Either agent is acceptable; clopidogrel may have slightly lower gastrointestinal bleeding risk. 3

Imaging Requirements:

Obtain repeat brain imaging before initiating antiplatelet therapy to confirm hemorrhage stability and assess for features predicting recurrent bleeding (microbleeds, superficial siderosis, lobar location). 2, 4

Evidence Quality and Limitations

The recommendation for antiplatelet resumption after ICH is currently Grade B evidence across multiple international guidelines (Canadian, American, UK, Chinese). 1 The RESTART trial showed no significant difference in recurrent ICH between starting versus avoiding antiplatelet therapy (hazard ratio 0.51,95% CI 0.25-1.03), though the study was underpowered. 1

Recent meta-analysis (2025) demonstrates: Early antiplatelet therapy significantly reduced recurrent ICH by 46% (RR 0.54,95% CI 0.37-0.78, p=0.001) without increasing major ischemic or hemorrhagic complications. 5 This represents the most recent high-quality evidence supporting earlier resumption than previously thought.

Ongoing Research:

The ASPIRING trial (starting mid-2024) aims to recruit 4,148 ICH survivors to definitively establish timing and effects of antiplatelet resumption, with results expected to provide Level A evidence. 1

Common Pitfalls to Avoid

• Do not automatically restart antiplatelet therapy without careful risk assessment of both bleeding and thrombotic risks. 2
• Do not use dual antiplatelet therapy in patients with ICH history—this significantly increases bleeding risk. 1, 2
• Do not ignore hemorrhage location—lobar hemorrhages have substantially higher recurrence risk than deep hemorrhages. 2
• Do not restart therapy without repeat imaging to confirm hemorrhage stability and assess for high-risk features. 2, 4

Practical Approach for Your Patient

Given your patient has multiple prior infarcts (high thromboembolic risk) and recent ICH (high bleeding risk):

1. Wait at least 7-14 days from ICH onset to allow hemorrhage stabilization. 2, 5
2. Obtain repeat brain imaging (CT or MRI with gradient echo sequences) to assess for microbleeds, hemorrhage location, and stability. 2
3. If deep hemorrhage with few/no microbleeds: Consider resuming antiplatelet monotherapy (aspirin 75-100 mg or clopidogrel 75 mg daily). 1, 2, 5
4. If lobar hemorrhage or multiple microbleeds: Strongly consider avoiding antiplatelet therapy unless thromboembolic risk is extremely high (e.g., recent stent, mechanical valve). 2
5. Never use dual antiplatelet therapy in this population. 1, 2