Should a patient with mild chronic microangiopathic disease in the brain, on aspirin (acetylsalicylic acid) 81mg daily and rosuvastatin 20mg daily, discontinue aspirin therapy after a small microhemorrhage is found in the left corona radiata?

Should Aspirin Be Discontinued After Finding a Small Microhemorrhage?

In a patient with mild chronic microangiopathic disease who develops a small microhemorrhage in the left corona radiata, aspirin should be discontinued if there is no compelling indication for antiplatelet therapy (such as recent acute coronary syndrome, coronary stent, or high-risk coronary disease requiring dual antiplatelet therapy). The presence of cerebral microbleeds indicates bleeding-prone cerebral microangiopathy, which substantially increases the risk of intracerebral hemorrhage with continued antiplatelet therapy.

Risk Assessment Framework

Bleeding Risk Factors Present

• Cerebral microhemorrhage is a major bleeding risk criterion that identifies patients at high risk for intracerebral hemorrhage 1
• Cerebral microbleeds represent remnants of blood extravasations from damaged vessels related to cerebral microangiopathies, indicating bleeding-prone vasculature 2
• Aspirin-associated intracerebral hemorrhage shows a propensity for lobar locations (32.8% vs 10.3% in non-aspirin users), suggesting the pathology differs in aspirin users with underlying microangiopathy 3
• Combined antithrombotic therapy in patients with bleeding-prone cerebral microangiopathy increases the risk of intracerebral hemorrhage 2

Ischemic Risk Assessment Required

The decision hinges on whether this patient has a compelling cardiovascular indication for aspirin:

• If no recent ACS or coronary stent: Aspirin for chronic stable coronary disease provides modest benefit (25% relative risk reduction in vascular events), but this must be weighed against substantially elevated hemorrhagic stroke risk in the presence of microbleeds 1
• If recent ACS (within 12 months) or coronary stent: The situation is more complex, as discontinuing aspirin carries ischemic risk 1

Clinical Decision Algorithm

For Patients WITHOUT Recent ACS or Coronary Stent:

Discontinue aspirin immediately 1, 3

• The bleeding risk from cerebral microangiopathy outweighs the ischemic benefit in chronic stable disease 1
• Continue rosuvastatin 20 mg daily, as statins reduce cardiovascular events without increasing bleeding risk 1
• Optimize other cardiovascular risk factors (blood pressure control is critical in microangiopathic disease) 1

For Patients WITH Recent ACS or Coronary Stent:

This scenario requires careful risk stratification:

• If within 1-4 weeks of ACS with indication for anticoagulation: Aspirin should be discontinued after this initial period, continuing with P2Y12 inhibitor (clopidogrel preferred) 1
• If 1-12 months post-ACS without anticoagulation indication: Consider discontinuing aspirin given the major bleeding risk criterion, though this represents a higher-risk decision requiring subspecialty consultation 1
• If >12 months post-ACS: Discontinue aspirin, as the acute ischemic risk has substantially declined and bleeding risk predominates 1

Evidence Supporting Aspirin Discontinuation in Microangiopathy

Bleeding Risk Evidence

• Aspirin increases hemorrhagic stroke risk, which is particularly concerning in patients with cerebral microangiopathy 1
• Case reports document cerebellar hemorrhage in patients with cerebral microbleeds taking aspirin combined with other antithrombotic agents 2
• Aspirin-associated intracerebral hemorrhage occurs more frequently in lobar locations, suggesting interaction with underlying small vessel disease 3

Ischemic Risk Mitigation

• In chronic stable coronary disease, aspirin reduces serious vascular events by approximately 1.5% per year, but this benefit diminishes when bleeding risk is elevated 1, 4
• Rosuvastatin provides substantial cardiovascular protection independent of antiplatelet therapy, with 22% relative risk reduction per 39 mg/dL LDL-C reduction 1
• Blood pressure control is paramount in microangiopathic disease and provides cardiovascular protection 1

Alternative Strategies

If Antiplatelet Therapy Deemed Essential:

• Clopidogrel monotherapy may be considered as it has slightly different bleeding profile than aspirin, though it still carries hemorrhagic risk 1, 4
• The CAPRIE trial showed clopidogrel reduced vascular events by 5.32% per year vs 5.83% with aspirin 4
• However, clopidogrel can also cause thrombotic microangiopathy in rare cases 5

Proton Pump Inhibitor Consideration:

• If aspirin must be continued, add PPI for gastrointestinal protection, though this does not mitigate intracerebral hemorrhage risk 1, 6

Critical Pitfalls to Avoid

• Do not continue aspirin without reassessing the indication: The presence of microhemorrhage fundamentally changes the risk-benefit calculation 1, 3
• Do not assume "low-dose" aspirin (81 mg) is safe: Even 75-100 mg daily increases hemorrhagic stroke risk in bleeding-prone microangiopathy 1, 2
• Do not add or continue other antithrombotic agents without compelling indication, as combination therapy substantially increases bleeding risk 2
• Do not neglect blood pressure optimization: Hypertension control is critical in cerebral microangiopathy and provides cardiovascular protection 1

Monitoring After Aspirin Discontinuation

• Continue rosuvastatin 20 mg daily and optimize to LDL-C <70 mg/dL or <55 mg/dL if very high risk 1
• Ensure blood pressure is controlled to target <130/80 mmHg 1
• Consider repeat brain MRI in 6-12 months to assess for new microhemorrhages 3
• If patient develops acute coronary syndrome in the future, the presence of cerebral microbleeds should inform antithrombotic strategy (shorter duration of dual therapy, early aspirin discontinuation) 1