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• The use of antithrombotic therapies to prevent thromboembolism
in patients with an acute or prior intracerebral hemorrhage (ICH)
presents a clinical dilemma with competing risks and benefits.
• In many cases, clinical decisions must be made on the basis of
indirect and observational evidence rather than high quality
clinical trials.
• Meta-analyses of aspirin use for primary and secondary
prevention of myocardial infarction and ischemic stroke
demonstrate a 15%–34% reduction in mortality, stroke, and
myocardial infarction but also a significant increase in the risk of
hemorrhagic stroke (12 events per 10,000 persons)
• There was no dose-response relationship between aspirin and risk
of hemorrhagic stroke in a meta-analysis, however

• Collaborative overview of randomised trials of antiplatelet therapy—I: prevention of death, myocardial infarction, and stroke by
prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration. BMJ 1994; 308(6921):81–106.
• He J, Whelton PK, Vu B, et al. Aspirin and risk of hemorrhagic stroke: a meta- analysis of randomized controlled trials. JAMA
Antithrombotic therapy after recent or
prior ICH
• ICH recurs in survivors at a rate of 2 to 3 percent per year.
Patients with lobar ICH, particularly if there is other evidence of
cerebral amyloid angiopathy have a higher rate of recurrence
compared to patients with deep ICH.
• Efforts to control blood pressure are likely to significantly reduce
the risk of recurrent ICH. The goal blood pressure should be less
than 140/90 mmHg.
• Antithrombotic therapies are associated with increased risk of
recurrent ICH. The highest risk is with warfarin anticoagulation
which is associated with a three- to five-fold increased risk of
recurrent ICH.
Antithrombotic therapy after recent or
prior ICH
• Use of long-term antiplatelet or anticoagulant drugs in ICH
survivors requires individual assessment of risks and
benefits. Only those ICH survivors with an exceptionally
high risk for atherothrombotic events should be treated
with antiplatelet drugs, and only those with very high risk
for cardioembolic stroke should be treated with
• There are conflicting data on the effect of previous
antiplatelet agent use on hematoma enlargement and
clinical outcome after ICH.
• Platelet dysfunction as measured by platelet function
assays has been associated with hematoma expansion
and worse outcome, but to date, platelet transfusion has
not been demonstrated to provide a mortality benefit or
improved functional outcome
Timing of antithrombotic therapy
• The optimal timing for restarting or initiating
anticoagulation therapy following an ICH is
unknown and is likely varies according to
patient-specific factors.
• The risk for hemorrhage expansion is highest
in the first hours and days after ICH, while the
risks of thromboembolism and recurrent ICH
accrue over time