Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage

Abstract

Objective Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long‐term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown. Methods We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included “antiplatelet,” “intracerebral hemorrhage,” “cerebral microbleeds,” “hematoma expansion,” “recurrent,” and “reinitiate.” Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed. Results When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients’ concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case‐by‐case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence‐based medicine evidence is needed in the future. Conclusion This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large‐scale randomized controlled trials are required.

Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage

“…We and others think that a definitive main phase RCT could resolve these remaining uncertainties and be integrated into physicians' clinical routine (Figure ). 47,62,[68][69][70][71][72][73] provided funding for ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage), to follow its external pilot phase (Table 4). This event-driven RCT aims to recruit 4148 CH survivors (2074 per group) over 4 years (starting in mid-2024) to detect 947 MACE primary outcome events over ≥1 year of follow-up if the MACE event rate is 11.1% per year in the comparator group, 19,41,49,67 to detect an effect size of 0.81 from antiplatelet agents (aspirin or clopidogrel) 5,51 with a 2-sided alpha of 0.05 and 90% power.…”