When can antiplatelet therapy be safely restarted after a hemorrhagic stroke in a patient with a recently placed coronary stent (drug‑eluting or bare‑metal)?

Antiplatelet Therapy Resumption After Hemorrhagic Stroke in Coronary Stent Patients

For patients with coronary stents who develop hemorrhagic stroke, restart antiplatelet monotherapy at 7–10 days after ICH onset if the hemorrhage has stabilized on repeat imaging and blood pressure is controlled (<130/80 mmHg), prioritizing P2Y12 inhibitor (clopidogrel) over aspirin for those within 1–3 months of stent placement. 1

Immediate Management (First 24–48 Hours)

• Discontinue all antiplatelet agents immediately upon ICH diagnosis and reverse any coagulopathy 2
• Do not restart antiplatelet therapy within the first 24–48 hours after ICH onset, as this substantially raises bleeding risk even in high-risk patients 1
• Obtain urgent neurosurgical consultation to assess hematoma stability and need for intervention 2

Risk Stratification Framework

Very High Thromboembolic Risk (Favoring Earlier Restart at 7–10 Days)

• Recent coronary stent placement within 1–3 months (especially drug-eluting stents) 1, 3
• Mechanical heart valves (thromboembolic risk >7% per year) 1
• CHADS₂ score ≥4 points (thromboembolic risk >7% per year) 1
• History of multiple prior ischemic strokes 1
• Recent acute coronary syndrome within 6 months 4

Lower Recurrent ICH Risk (Favoring Earlier Restart)

• Deep hemorrhage location (basal ganglia, thalamus) rather than lobar 1, 3
• Adequate blood pressure control (<130/80 mmHg) 3
• Absence of multiple microbleeds on gradient-echo MRI 1, 3
• Age <70 years 3

Higher Recurrent ICH Risk (Favoring Delayed Restart at 4–6 Weeks)

• Lobar hemorrhage location (suggests cerebral amyloid angiopathy) 1, 3
• Age >70 years with lobar ICH 3
• Multiple cerebral microbleeds on MRI (≈9% ICH risk vs ≈1% without) 3
• Uncontrolled hypertension (>130/80 mmHg raises recurrent ICH risk ≈4.3-fold) 3

Timing Algorithm

For Patients Within 1–3 Months of Coronary Stent Placement

At 7–10 days after ICH onset:

• Obtain repeat brain imaging (CT or MRI) to confirm hemorrhage stability 3
• Verify blood pressure control (<130/80 mmHg) 3
• Confirm neurological stability (no deterioration) 3
• Restart P2Y12 inhibitor monotherapy (clopidogrel 75 mg daily preferred) 1
• Stop aspirin if dual antiplatelet therapy was being used 1

For Patients >3 Months Post-Stent or Other High Thromboembolic Risk

At 7–10 days after ICH onset (if very high risk):

• Restart aspirin 75–100 mg daily after confirming hemorrhage stability on repeat imaging 1, 3
• This applies to mechanical heart valves, CHADS₂ ≥4, or multiple prior strokes 1

At 4–6 weeks after ICH onset (if lower thromboembolic risk):

• Consider delayed restart for stable coronary disease without recent events 1, 3
• Mandatory for lobar ICH or elderly patients with suspected amyloid angiopathy 3

Medication Selection

• Clopidogrel 75 mg daily is preferred for patients within 1–3 months of coronary stent placement 1, 3
• Aspirin 75–100 mg daily is acceptable for other indications and has slightly higher GI bleeding risk 1, 3
• Never use dual antiplatelet therapy after ICH due to markedly increased bleeding risk 1, 3
• Stop standard DAPT duration (usually 1–3 months post-stenting) when considered safe 1

Mandatory Pre-Restart Requirements

1. Repeat brain imaging showing no hematoma expansion 3
2. Blood pressure <130/80 mmHg on stable antihypertensive regimen 3
3. Stable neurological examination without deterioration 3
4. Consultation with interventional cardiologist to confirm stent thrombosis risk 1

Evidence Quality

The RESTART trial (2019) provides the highest-quality evidence, showing antiplatelet resumption did not increase recurrent ICH risk (adjusted HR 0.51,95% CI 0.25–1.03, p=0.060) and may actually reduce it 2, 5. This counterintuitive finding suggests antiplatelet therapy after ICH is safer than previously assumed 2.

Current guideline consensus (American Heart Association, Canadian Stroke Guidelines, UK/Ireland, Chinese Guidelines) classifies this as Level B evidence and indicates antiplatelet agents "may be considered/reasonable" after ICH associated with antithrombotic use 2, 1.

A 2025 meta-analysis of 5,554 patients demonstrated early antiplatelet therapy significantly reduced recurrent ICH by 46% (RR 0.54,95% CI 0.37–0.78, p=0.001) without increasing ischemic complications 6.

Critical Pitfalls to Avoid

• Do not restart without repeat imaging confirming hemorrhage stability 3
• Do not restart if blood pressure remains >130/80 mmHg 3
• Do not use dual antiplatelet therapy after any ICH 1, 3
• Do not automatically restart at 24–48 hours even for recent stents 1
• Do not withhold both antiplatelet agents simultaneously in dual therapy patients, as median time to stent thrombosis is only 7 days with both drugs withheld versus 122 days with only clopidogrel withheld 4
• Do not ignore hemorrhage location when timing restart—lobar ICH requires more caution 1, 3

Special Considerations for Hemorrhagic Transformation

Hemorrhagic transformation of ischemic stroke has a different natural history than primary ICH 1. Continuing antiplatelet therapy may be reasonable if the transformation is asymptomatic and there is compelling indication 2, 1. Antiplatelet monotherapy can be safely resumed at 7–10 days after hemorrhagic transformation if the hemorrhage has stabilized 1.

Ongoing Research

The ASPIRING trial is recruiting 4,148 ICH survivors to provide definitive Level A evidence on antiplatelet timing and safety after ICH, with results expected to clarify remaining uncertainties about optimal timing and subgroup effects 2, 1.