When can antiplatelet therapy, such as aspirin (acetylsalicylic acid), be restarted in a patient with partial anterior circulation stroke complicated by acute punctate intracranial hemorrhage?

Restarting Antiplatelet Therapy After Partial Anterior Circulation Stroke with Acute Punctate Intracranial Hemorrhage

Aspirin can be safely restarted beyond 24 hours after symptom onset in patients with partial anterior circulation stroke complicated by acute punctate intracranial hemorrhage, provided the hemorrhage has stabilized on repeat imaging and blood pressure is adequately controlled. 1, 2

Immediate Management

• Stop aspirin immediately upon diagnosis of intracranial hemorrhage to prevent hematoma expansion 1
• Obtain baseline CT or MRI to document hemorrhage size and location 1
• Achieve blood pressure control with target <130/80 mmHg 1

Standard Timing for Aspirin Resumption

The optimal timing is 24-48 hours after stroke onset for patients with ischemic stroke and small punctate hemorrhage, based on international stroke guidelines 3, 1. This recommendation is supported by:

• The RESTART trial demonstrated no increased risk of recurrent intracranial hemorrhage with antiplatelet resumption (adjusted HR 0.51,95% CI 0.25-1.03) 1, 4
• A 2025 meta-analysis showed early antiplatelet therapy reduced recurrent intracerebral hemorrhage by 46% (RR 0.54,95% CI 0.37-0.78) 5
• Observational studies demonstrate lower ischemic events (RR 0.61) with no difference in hemorrhagic events (RR 0.84) when aspirin is resumed 1

Pre-Restart Requirements Checklist

Before restarting aspirin at 24-48 hours, you must confirm:

• Repeat brain imaging (CT or MRI) shows hemorrhage stability with no expansion 1, 2
• Blood pressure adequately controlled to target <130/80 mmHg 1
• Patient clinically stable without declining neurological status 2
• Document absence of new microbleeds if MRI with gradient echo sequences is available 1

Risk Stratification Algorithm

High-Risk Features Requiring Delayed Restart (Wait 7-10 Days or Longer):

• Lobar hemorrhage location (suggests cerebral amyloid angiopathy with highest recurrence risk) 1, 4
• Elderly patients (>70 years) with lobar hemorrhage 3, 4
• Multiple microbleeds on gradient echo MRI (9.3% ICH risk on antithrombotics vs 1.3% without) 1
• Hemorrhage expansion on repeat imaging 1
• Uncontrolled hypertension 1

Features Favoring Earlier Restart (24-48 Hours):

• Deep (non-lobar) punctate hemorrhage 1, 4
• High thromboembolic risk (CHADS₂ score ≥4, recent MI, recent coronary stenting) 1, 2
• Hemorrhagic transformation within ischemic stroke (different natural history than primary ICH) 4
• Stable hemorrhage on repeat imaging 1

Medication Selection

• Aspirin monotherapy 75-100 mg daily is preferred over dual antiplatelet therapy 1, 4
• Clopidogrel 75 mg daily is an acceptable alternative with slightly lower GI bleeding risk 4
• Avoid dual antiplatelet therapy after hemorrhagic stroke due to significantly increased bleeding risk 4

Special Considerations for Partial Anterior Circulation Stroke

For patients with partial anterior circulation stroke (PACS) specifically:

• PACS typically has moderate stroke severity, allowing for standard 24-48 hour restart timing if hemorrhage is punctate and stable 3
• If the stroke is classified as "moderate" in size despite being PACS territory, consider waiting 6-8 days before restart 3
• Punctate hemorrhage (small, dot-like) carries lower rebleeding risk than larger hemorrhages, supporting earlier restart 1

Common Pitfalls to Avoid

• Do not automatically restart without repeat imaging to confirm hemorrhage stability 1
• Do not use dual antiplatelet therapy in patients with any history of ICH 4
• Do not restart if blood pressure remains uncontrolled (>130/80 mmHg) 1
• Do not ignore hemorrhage location—lobar hemorrhages have significantly higher recurrence risk than deep hemorrhages 1, 4
• Do not delay unnecessarily in high thromboembolic risk patients with stable deep hemorrhages, as ischemic risk may outweigh bleeding risk 1, 2

Alternative Strategies for High-Risk Patients

• Consider left atrial appendage closure for atrial fibrillation patients who cannot safely restart antiplatelets 1, 4
• Aspirin monotherapy appears generally safe even in cerebral amyloid angiopathy patients when restarted beyond 24 hours 1