antiplatelets after ICH - Is it adding insult to injury??

Antiplatelets are an indispensible tool in managing atherosclerotic disease (CVS & stroke especially). The main problem with these agents have been the risk of bleeding (mostly GI bleeding & intracranial bleed). They definitely pose a bigger risk for intracerebral bleed(ICH) than patients not on antiplatelets. But since benefits outweigh this risk...we have patients on antiplatelets all the time!
This leads to 2 questions!!


1. Do patients with ICH do worse if they were on antiplatelets Vs not been on antiplatelets before the event?
It appears that patients who are on antiplatelets ,and have an ICH are 3 times more likely to die at 30 days than patients with ICH who were not on an antiplatelet.(Stroke 2007). A metanalysis of 25 studies published in (Neurology.Sept 2010) also supported the fact that prior antiplatelet use independently predicted worse mortality in case of ICH.


2. Can antiplatelets be started again in patients after an ICH. and if so..when?
The answer is YES(provided they have a compelling reason to use). The answer came up with the recent study from UK..published in Stroke.Oct 2010. 120 patients out of 417 pts who survived a ICH were prescribed antipletelet therapy. The median time from discharge to antiplatelet use was 14.8 months (range, 2 days–7.5 years).Among all survivors, there were 14 recurrent ICH, 29 subsequent ischemic strokes , and 40 subsequent ischemic strokes or myocardial infarctions .Hazard ratios associated with antiplatelet exposure were 1.07 (95% CI, 0.24–4.84) for recurrent ICH, 0.23 (95% CI, 0.03–1.68) for ischemic stroke, and 0.72 (95% CI, 0.25–2.02) for ischemic strokes or myocardial infarction. So, antiplatelet use was not associated with worse outcome.....and in fact MI & ischemic stroke were more common in this group than ICH.


A review published in Nature Neurology 2006...also concluded that antiplatelets after ICH do not increase the risk of a second ICH.
Based on this recent study....a better time to start antiplatelets would be  between 6 months to 1 year ...again ..provided there is a strong indication to restart them (coronary stents, A fib etc)