Clopidogrel and Aspirin Should NOT Be Given to Hemorrhagic Stroke Patients
In patients with a history of intracerebral hemorrhage (ICH), long-term antithrombotic therapy including clopidogrel and aspirin should be avoided for stroke prevention. 1
Primary Recommendation for Hemorrhagic Stroke
The American College of Chest Physicians explicitly recommends AGAINST the long-term use of antithrombotic therapy (including both aspirin and clopidogrel) for the prevention of ischemic stroke in patients with a history of symptomatic primary intracerebral hemorrhage (Grade 2C). 1
This recommendation prioritizes the risk of rebleeding, which carries devastating morbidity and mortality consequences that outweigh potential benefits of stroke prevention in most hemorrhagic stroke patients. 1
Rare Exceptions Where Antithrombotic Therapy Might Be Considered
The guidelines acknowledge extremely limited circumstances where antiplatelet therapy might be considered, but only in highly selected patients: 1
- Patients at relatively LOW risk of recurrent ICH (specifically those with deep hemorrhages, not lobar hemorrhages) AND 1
- Patients at very HIGH risk of thromboembolic events (>7% per year), such as those with mechanical heart valves or CHADS₂ scores ≥4 points 1
Even in these exceptional cases, the decision requires careful weighing of competing risks, and most hemorrhagic stroke patients will not meet these criteria. 1
Critical Distinction: Hemorrhagic vs. Ischemic Stroke
The evidence you may have encountered regarding clopidogrel and aspirin applies exclusively to ischemic stroke, not hemorrhagic stroke: 1
- For ischemic stroke/TIA: Antiplatelet therapy with aspirin, clopidogrel, or their combination is standard of care 1
- For hemorrhagic stroke: Antiplatelet therapy is contraindicated in the vast majority of cases 1
Common Pitfall to Avoid
Never confuse treatment recommendations for ischemic stroke with those for hemorrhagic stroke. The pathophysiology is fundamentally opposite—ischemic stroke results from thrombosis requiring antiplatelet therapy, while hemorrhagic stroke results from bleeding where antiplatelet agents would increase rebleeding risk and worsen outcomes. 1
If a patient with prior hemorrhagic stroke requires urgent management of intracranial hemorrhage and is on antiplatelet therapy, immediate discontinuation of all antiplatelets is required for at least 1-2 weeks. 2