What is the treatment for an asymptomatic patient with post-traumatic intracranial bleeding (ICB) and an incidental finding of stroke on computed tomography (CT) brain, specifically regarding aspirin use for future stroke prevention?

Management of Post-Traumatic Intracranial Bleeding with Incidental Stroke Finding

Do not start aspirin while active intracranial bleeding is present; wait until the traumatic ICB has stabilized on repeat imaging (typically 24-48 hours), then initiate aspirin for secondary stroke prevention once bleeding risk has resolved. 1

Immediate Management of Active Traumatic ICB

Hold All Antiplatelet Therapy During Active Bleeding

• Aspirin must be withheld during the acute phase of traumatic intracranial bleeding, regardless of the incidental stroke finding 1
• The bleeding risk from active traumatic ICB outweighs stroke prevention benefits in the immediate post-injury period 1
• Monitor hemoglobin levels and vital signs to ensure hemodynamic stability during the observation period 1

Imaging Protocol for Traumatic ICB

• Obtain repeat head CT at 24-48 hours to assess for progression of intracranial hemorrhage 2
• Patients with stable or improving ICB on repeat imaging can be considered for aspirin initiation 2
• If ICB progresses on repeat imaging, continue to hold aspirin and repeat CT in another 24-48 hours 3

Timing of Aspirin Initiation for Stroke Prevention

When to Start Aspirin

• Resume aspirin 24-48 hours after traumatic ICB has stabilized on repeat CT imaging 1, 2
• Start with aspirin 75-100 mg daily (not 325 mg loading dose) once bleeding has resolved 1
• Do not use loading doses when initiating therapy after intracranial bleeding 1

Evidence Supporting Early Aspirin After Stabilization

• Low-dose aspirin (81 mg) does not increase progression of traumatic ICB once initial bleeding has stabilized 2, 4
• Aspirin started within 48 hours of ischemic stroke reduces early recurrent stroke by 10 per 1,000 patients without significantly increasing intracranial hemorrhage 5
• The stroke prevention benefit outweighs minor bleeding risks once active hemorrhage has resolved 1

Long-Term Secondary Stroke Prevention Strategy

Antiplatelet Regimen Selection

• For asymptomatic incidental stroke: aspirin 75-325 mg daily is the recommended first-line therapy 6
• Aspirin monotherapy is preferred over anticoagulation for secondary stroke prevention in arterial (non-cardiac) stroke 6, 7
• Alternative options include clopidogrel 75 mg daily or aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily if aspirin is not tolerated 6

What NOT to Do

• Never use warfarin or other anticoagulation for secondary prevention of arterial stroke - it increases major bleeding (including intracranial hemorrhage) without improving outcomes compared to aspirin 6, 7
• Do not use dual antiplatelet therapy (aspirin plus clopidogrel) beyond 90 days - this increases bleeding risk without additional stroke prevention benefit in stable patients 6
• Avoid high-intensity anticoagulation (INR 3.0-4.5) which caused excess intracranial hemorrhage and death in arterial stroke patients 7

Risk Factor Management Alongside Aspirin

Blood Pressure Control

• Target systolic blood pressure <140 mm Hg for long-term stroke prevention 6
• Aggressive BP control reduces recurrent stroke risk even in patients with large vessel disease 6

Lipid Management

• Initiate high-intensity statin therapy targeting LDL <70 mg/dL 6
• Lower LDL levels are associated with reduced vascular events in stroke patients 6

Monitoring After Aspirin Initiation

Short-Term Surveillance

• Check hemoglobin 24-48 hours after starting aspirin to ensure no occult bleeding 1
• Monitor for signs of recurrent intracranial bleeding for 72 hours 1
• Repeat neurological examination to detect any new deficits 1

Long-Term Management

• Maintain lifelong antiplatelet therapy for secondary stroke prevention 1, 6
• Antiplatelet therapy reduces recurrent stroke, MI, and vascular death even in patients with prior bleeding events 1
• Counsel patients not to stop therapy for minor bleeding or bruising without physician consultation 1

Common Pitfalls to Avoid

• Do not permanently withhold aspirin due to the traumatic ICB - once stabilized, the stroke prevention benefit outweighs bleeding risk 1, 2, 4
• Do not delay aspirin indefinitely waiting for "complete resolution" of ICB on imaging - stability (not complete resolution) is the threshold 2
• Do not use platelet transfusions in aspirin-treated patients with traumatic ICB - they do not improve platelet function or prevent ICB progression 3
• Avoid routine repeat head CTs beyond the initial 24-48 hour scan in stable patients on low-dose aspirin - this is not cost-effective and does not change management 2