What are the guidelines on secondary stroke prevention in patients with a history of intracranial hemorrhage?

Updated: Jan 10, 2016
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In general, the ACCP guidelines recommend against long-term use of antithrombotic therapy for secondary prevention of stroke in patients with a history of symptomatic intracranial hemorrhage (ICH) (grade 2C); however, patients who might benefit from antithrombotic therapy are those at relatively low risk of recurrent ICH (eg, with deep hemorrhages) and relatively high risk (>7% per year) of cardiac thromboembolic events (eg, with mechanical heart valves or CHADS2 score >4). [11]

The AHA/ASA guidelines recommend that the decision to restart antithrombotic therapy after ICH related to antithrombotic therapy be individualized based on the risk of subsequent arterial or venous thromboembolism, the risk of recurrent ICH, and the overall status of the patient. Additional recommendations include the following:

  • Consider an antiplatelet agent for patients with a comparatively lower risk of cerebral infarction (eg, AF without prior ischemic stroke) and a higher risk of recurrent ICH (eg, elderly patients with lobar ICH or presumed amyloid angiopathy) or with very poor overall neurological function (class IIb)
  • For patients who require resumption or initiation of anticoagulation, the optimal timing is uncertain; for most patients, however, waiting ≥1 week might be reasonable (class IIb)

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