What are the recommended discharge medications for a patient who survived a cerebrovascular hemorrhage (including subarachnoid hemorrhage) to achieve blood pressure control, secondary atherosclerotic prevention, and vasospasm prophylaxis while avoiding antiplatelet or anticoagulant therapy unless specifically indicated?

Discharge Medications for Cerebrovascular Hemorrhage

Blood Pressure Management

For patients with intracerebral hemorrhage (ICH), strict blood pressure control is the cornerstone of discharge management, with a target systolic BP <140 mmHg to prevent rebleeding. 1

• Initiate antihypertensive therapy before discharge with agents such as ACE inhibitors, ARBs, or calcium channel blockers 1
• Avoid severe hypotension, hypertension, and blood pressure variability in the acute phase 1
• For patients with unsecured aneurysms (if applicable), BP control is critical but specific targets are not rigidly defined 1

Antiplatelet and Anticoagulant Therapy: Critical Decision Points

Antiplatelet agents should NOT be routinely prescribed at discharge after ICH unless there is a compelling indication for secondary prevention of major adverse cardiovascular events (MACE) that outweighs hemorrhage risk. 1

When to Consider Antiplatelet Therapy After ICH

• For ICH survivors with prior history of MACE or atrial fibrillation who were on antithrombotic therapy at the time of hemorrhage: antiplatelet monotherapy (aspirin 75-100 mg daily OR clopidogrel 75 mg daily) may be considered after careful risk-benefit assessment, typically starting 4-8 weeks post-hemorrhage 1
• The RESTART trial demonstrated that antiplatelet therapy in high-risk ICH survivors did not increase recurrent ICH risk compared to avoiding antiplatelets 1
• Do NOT use dual antiplatelet therapy (DAPT) after ICH - this is contraindicated due to excessive bleeding risk 1, 2

Absolute Contraindications to Antiplatelet Therapy

• Large ICH with hemorrhagic conversion 2
• Ongoing hemorrhagic transformation on imaging 2
• ICH involving >1/3 of vascular territory 2
• Uncontrolled hypertension 2

Subarachnoid Hemorrhage (SAH) Specific Management

For aneurysmal SAH survivors, nimodipine 60 mg every 4 hours orally for 21 days is the ONLY FDA-approved medication proven to improve neurological outcomes by reducing delayed cerebral ischemia. 1, 3, 4, 5

Nimodipine Protocol

• Start immediately after diagnosis and continue for exactly 21 days 1
• Dose: 60 mg orally every 4 hours (total 360 mg/day) 1
• If hypotension occurs, reduce to 30 mg every 4 hours 1
• This is a Class I, Level A recommendation - the single most important discharge medication for SAH 1

Vasospasm Prophylaxis: What NOT to Prescribe

• Routine statin therapy is NOT recommended for improving outcomes after SAH 1
• Routine IV magnesium is NOT recommended for improving outcomes 1
• Prophylactic hemodynamic augmentation (triple-H therapy) should NOT be performed 1
• Endothelin antagonists have no proven benefit 1

Venous Thromboembolism (VTE) Prophylaxis

Once the aneurysm is secured (clipped or coiled), initiate pharmacologic VTE prophylaxis with subcutaneous heparin or low-molecular-weight heparin. 1

• For ICH patients: delay VTE prophylaxis until hemorrhage is stable (typically 48-72 hours) and repeat imaging confirms no expansion 1
• Use mechanical prophylaxis (sequential compression devices) in the interim 1

Seizure Prophylaxis

Phenytoin for seizure prevention is associated with excess morbidity and mortality and should be AVOIDED. 1

• If seizure prophylaxis is deemed necessary, use levetiracetam instead 1
• Routine prophylactic anticonvulsants are not recommended for most hemorrhagic stroke patients 1

Lipid Management

High-dose statin therapy is NOT routinely indicated for hemorrhagic stroke survivors unless there is concurrent atherosclerotic disease requiring secondary prevention. 1

• If the patient has coexisting ischemic vascular disease, consider atorvastatin 80 mg daily or rosuvastatin 20-40 mg daily 1

Anticoagulation Reversal and Future Use

Emergency reversal of anticoagulation should be performed acutely, but decisions about restarting anticoagulation require careful individualized assessment. 1

• For patients with atrial fibrillation and ICH, anticoagulation may be cautiously restarted 4-8 weeks after hemorrhage if the risk of ischemic stroke substantially outweighs rebleeding risk 1
• Avoid anticoagulation indefinitely if possible in ICH survivors 1

Discharge Medication Checklist for ICH

1. Antihypertensive agent(s) targeting SBP <140 mmHg 1
2. VTE prophylaxis (once stable) 1
3. Avoid antiplatelet agents unless compelling MACE indication 1
4. Avoid routine statins unless atherosclerotic disease present 1
5. Avoid phenytoin for seizure prophylaxis 1

Discharge Medication Checklist for SAH

1. Nimodipine 60 mg every 4 hours for 21 days (mandatory) 1, 4, 5
2. Antihypertensive agent(s) targeting SBP <160 mmHg 1
3. VTE prophylaxis after aneurysm secured 1
4. Avoid statins, magnesium, and endothelin antagonists 1
5. Avoid phenytoin 1

Common Pitfalls to Avoid

• Never prescribe aspirin or clopidogrel reflexively at discharge after hemorrhagic stroke - this requires explicit justification based on competing ischemic risk 1
• Never omit nimodipine in SAH patients - it is the only proven therapy 1, 4, 5
• Never use triple-H therapy prophylactically - it is potentially harmful 1
• Never continue anticoagulation without a multidisciplinary discussion weighing stroke vs. bleeding risk 1