When can antiplatelet therapy be safely restarted after a hypertensive basal‑ganglia intracerebral hemorrhage once blood pressure is controlled and imaging shows stability?

Restarting Antiplatelet Therapy After Hypertensive Basal Ganglia Hemorrhage

Restart antiplatelet therapy at 7-10 days after hypertensive basal ganglia hemorrhage once blood pressure is controlled (<130/80 mmHg) and repeat imaging confirms hemorrhage stability, particularly if the patient has high thromboembolic risk (mechanical heart valve, CHADS₂ ≥4, or recent stent within 1-3 months). 1, 2, 3

Evidence-Based Timing Framework

Standard Timing (Most Patients)

• Restart at 24-48 hours after hemorrhage onset for patients with compelling indications and small/punctate hemorrhage, provided imaging shows stability 2
• Restart at 7-10 days for patients with moderate thromboembolic risk (CHADS₂ 2-3, prior ischemic stroke, or coronary artery disease) after confirming hemorrhage stability 2, 3, 4
• Restart at 4-6 weeks for lower-risk patients or when uncertainty exists about hemorrhage stability 1, 3

High-Risk Thromboembolic Patients (>7% annual risk)

• Restart at 7-10 days for mechanical heart valves (especially mitral position), CHADS₂ ≥4, or recent coronary/carotid stent within 1-3 months 2, 3, 4
• The RESTART trial showed antiplatelet resumption did not increase recurrent ICH risk (adjusted HR 0.51,95% CI 0.25-1.03) and may actually reduce it 1
• Recent meta-analysis (2025) demonstrated 46% reduction in recurrent ICH with early antiplatelet therapy (RR 0.54,95% CI 0.37-0.78) 5

Mandatory Pre-Restart Requirements

All three criteria must be met before restarting antiplatelet therapy:

1. Repeat brain imaging (CT or MRI) confirms hemorrhage stability with no expansion 1, 2, 3
2. Blood pressure adequately controlled to <130/80 mmHg 2, 3, 6
3. Patient clinically stable without declining neurological status 2

Why Basal Ganglia Location Matters

• Deep hemorrhages (basal ganglia, thalamus) carry LOWER recurrence risk compared to lobar hemorrhages 1, 4
• Basal ganglia hemorrhages are typically hypertensive in etiology, not cerebral amyloid angiopathy (CAA), which has much higher rebleeding risk 1, 6
• This favorable location profile supports earlier antiplatelet resumption compared to lobar hemorrhages 4

Medication Selection

Use antiplatelet monotherapy only—never dual antiplatelet therapy after ICH:

• Aspirin 75-100 mg daily is the preferred first-line agent 1, 2, 4
• Clopidogrel 75 mg daily is an acceptable alternative with slightly lower GI bleeding risk 2, 4
• Never use dual antiplatelet therapy (aspirin + clopidogrel) after any ICH due to significantly increased bleeding risk 2, 4

Risk Stratification Algorithm

Factors FAVORING Earlier Restart (7-10 days):

• Deep/basal ganglia hemorrhage location 4
• Mechanical heart valve 3, 4
• CHADS₂ score ≥4 3, 4
• Recent coronary or carotid stent (within 1-3 months) 4
• Prior multiple ischemic strokes 4
• Controlled blood pressure (<130/80 mmHg) 2, 6

Factors DELAYING Restart (4-6 weeks or avoid):

• Lobar hemorrhage location (suggests CAA) 1, 4
• Age >70 years with lobar hemorrhage 2
• Multiple microbleeds on gradient echo MRI (9.3% ICH risk vs 1.3% without) 2, 3
• Uncontrolled blood pressure (>130/80 mmHg) 2, 6
• Renal dysfunction (increases rebleeding risk 4.6-fold) 7

Current Guideline Consensus (2023)

Multiple international guidelines now support antiplatelet resumption after ICH 1:

• American Heart Association (2023): Resumption of antiplatelet therapy is reasonable for prevention of thromboembolic events (Class IIa, Level B-R) 1
• Canadian Stroke Guidelines (2023): Resuming antiplatelet treatment is reasonable in patients with continued indication (Level B) 1
• UK/Ireland Guidelines (2023): Patients may be considered for restarting antiplatelet treatment beyond 24 hours after ICH symptom onset 1
• Chinese Guidelines (2023): Aspirin monotherapy can be restored within a few days from ICH onset (Level B) 1

Critical Pitfalls to Avoid

1. Do NOT restart without repeat imaging to confirm hemorrhage stability—this is the most common error 2, 3
2. Do NOT restart if blood pressure remains >130/80 mmHg—inadequate BP control increases recurrent ICH risk 4.3-fold 2, 6
3. Do NOT use dual antiplatelet therapy after any ICH—this significantly increases bleeding risk 2, 4
4. Do NOT automatically avoid antiplatelets in all ICH patients—ischemic events (6.8 per 100 patient-years) exceed recurrent ICH (2.6 per 100 patient-years) when antiplatelets are withheld 8, 6

Alternative Strategies for Contraindicated Patients

• Left atrial appendage closure for atrial fibrillation patients who cannot safely restart antiplatelets 2, 3
• Aspirin monotherapy appears generally safe even in CAA patients when restarted beyond 24 hours, though this remains controversial 2, 3

Evidence Quality Assessment

The RESTART trial (2019) remains the highest-quality RCT evidence, though it was underpowered as a pilot study 1. The ongoing ASPIRING trial (recruiting 4,148 patients) will provide definitive Level A evidence when completed 4. Current recommendations are based on Level B evidence from RESTART combined with observational studies showing antiplatelet resumption does not increase recurrent ICH risk 1, 7, 8, 6, 5.