What is the recommended follow-up for an elderly male with gross hematuria after an embolic stroke, who has started antiplatelet therapy, such as aspirin (acetylsalicylic acid) or clopidogrel, and has had bleeding cleared by computed tomography (CT) scan?

Management of Gross Hematuria After Antiplatelet Initiation Post-Embolic Stroke

Continue antiplatelet therapy immediately after the bleeding has been cleared by continuous bladder irrigation (CBI), as the risk of recurrent embolic stroke significantly outweighs the bleeding risk in this clinical scenario. 1

Immediate Post-Bleeding Management

Antiplatelet Resumption

• Resume aspirin (81-325 mg daily) as soon as the hematuria has cleared with CBI 1
• The Canadian Stroke Best Practice guidelines emphasize that antiplatelet therapy should be continued indefinitely after acute stroke unless there is active, uncontrolled bleeding 1
• Since the bleeding has been successfully cleared with CBI, this no longer represents an absolute contraindication to antiplatelet therapy 2

Risk-Benefit Assessment

• In embolic stroke patients, the absolute risk of recurrent stroke without antiplatelet therapy is substantially higher than the risk of recurrent hematuria 1
• The American Heart Association notes that temporary interruption of antiplatelet therapy increases cardiovascular event risk, and therapy should be restarted as soon as hemostasis is achieved 3
• For elderly patients specifically, while bleeding risk is elevated, the mortality and morbidity from recurrent embolic stroke is catastrophic 2

Urological Follow-Up Protocol

Mandatory Evaluation

• Schedule urgent urology consultation within 1-2 weeks to evaluate for underlying bladder pathology 2
• Gross hematuria in an elderly patient on antiplatelet therapy may unmask underlying malignancy or other structural lesions that would have eventually bled regardless of antiplatelet use 2
• Cystoscopy and upper tract imaging (CT urography or renal ultrasound) should be performed to exclude bladder cancer, stones, or other structural abnormalities 2

Timing Considerations

• The urological workup can be performed while the patient continues antiplatelet therapy, as diagnostic cystoscopy carries minimal bleeding risk 2
• Do not delay antiplatelet resumption while awaiting urological evaluation, as stroke risk is time-sensitive 1

Antiplatelet Regimen Optimization

Monotherapy vs. Dual Therapy Decision

• If this was an embolic stroke from a cardioembolic source (e.g., atrial fibrillation), anticoagulation—not antiplatelet therapy—is the appropriate long-term treatment 1, 4
• If this was a non-cardioembolic embolic stroke and the patient is within 21-30 days of stroke onset, dual antiplatelet therapy (aspirin + clopidogrel) may still be indicated despite the bleeding episode 1, 5
• However, given the recent hematuria, consider aspirin monotherapy rather than dual therapy to reduce bleeding risk while maintaining stroke prevention 1, 2

Alternative Antiplatelet Options

• If hematuria recurs on aspirin, switch to clopidogrel 75 mg daily as monotherapy, which may have a lower genitourinary bleeding risk profile 2, 4
• The American Heart Association recommends clopidogrel as a reasonable alternative for patients who cannot tolerate aspirin due to bleeding 2

Bleeding Risk Mitigation Strategies

Gastrointestinal Protection

• Add a proton pump inhibitor (PPI) for gastrointestinal protection, particularly important in elderly patients on antiplatelet therapy 1
• The Canadian Stroke guidelines specifically recommend GI protection for patients at higher risk of bleeding 1

Blood Pressure Control

• Ensure strict blood pressure control (target <130/80 mmHg) to reduce risk of both recurrent stroke and bleeding complications 1
• Uncontrolled hypertension significantly increases the risk of both ischemic and hemorrhagic complications 1

Monitoring Parameters

• Monitor hemoglobin/hematocrit at 1 week, 2 weeks, and 1 month after resuming antiplatelet therapy 2
• Educate patient to report any recurrence of visible blood in urine, significant bruising, or other bleeding symptoms 2, 3

Common Pitfalls to Avoid

Critical Errors

• Do not withhold antiplatelet therapy indefinitely after a single episode of hematuria that has resolved—this dramatically increases stroke recurrence risk and mortality 1, 2, 3
• Do not assume the hematuria was solely due to antiplatelet therapy without urological investigation—elderly patients require cancer screening regardless 2
• Do not use dual antiplatelet therapy beyond 21-30 days post-stroke, as bleeding risk increases substantially without additional stroke prevention benefit 1

Timing Mistakes

• Avoid delaying antiplatelet resumption for more than 24-48 hours after bleeding control, as early recurrent stroke risk is highest in the first weeks 1, 5
• Do not wait for complete urological workup before restarting antiplatelet therapy 2

Long-Term Management Plan

Follow-Up Schedule

• Week 1: Verify hematuria resolution, check hemoglobin, ensure antiplatelet compliance 2
• Week 2-4: Urology consultation with cystoscopy and imaging 2
• Month 1: Reassess bleeding symptoms, hemoglobin, and stroke symptoms 2
• Month 3: If on dual antiplatelet therapy, transition to monotherapy at this point 1, 5

Stroke Mechanism Clarification

• Confirm whether this was truly an embolic stroke versus other mechanism (atherosclerotic, lacunar) as this determines optimal long-term antithrombotic strategy 1, 4
• If cardioembolic source identified (atrial fibrillation, left ventricular thrombus, valvular disease), transition to anticoagulation rather than antiplatelet therapy once bleeding risk is reassessed 1, 4