Aspirin Therapy in Malignant Cerebral Infarction

Initial Management

The American Heart Association/American Stroke Association recommends starting aspirin 160-325 mg within 24-48 hours of stroke onset for uncomplicated malignant cerebral infarction without hemorrhagic transformation, but if the patient received IV thrombolysis, delay aspirin for at least 24 hours after thrombolytic administration 1, 2
Brain imaging is required to exclude intracranial hemorrhage or hemorrhagic transformation of the infarct before initiating aspirin therapy 3

For patients who did not receive thrombolysis, start aspirin 160-325 mg within 24-48 hours of symptom onset, which provides a small but statistically significant reduction in mortality and morbidity 1, 4
If IV thrombolysis was administered, delay aspirin until at least 24 hours after thrombolytic therapy to avoid increasing the risk of serious intracranial hemorrhage 1, 3
The loading dose of aspirin is 160-325 mg when initiating therapy 1, 3

For non-lobar hemorrhagic transformation with strong antiplatelet indications, restart aspirin at 3-7 days post-hemorrhage if the patient is clinically stable 3, 5
For lobar hemorrhagic transformation or weaker indications, delay aspirin for a minimum of 4-6 weeks 3, 5
Do not use aspirin as a substitute for acute stroke interventions, including IV thrombolysis or mechanical thrombectomy (Class III recommendation) 1, 4
Do not combine aspirin with clopidogrel for treatment of acute malignant infarct unless the stroke is minor (NIHSS ≤3) 1, 2

High-risk features for hemorrhagic complications include lobar location of any hemorrhagic transformation, older age, presence and number of microbleeds on gradient echo MRI, and Apolipoprotein E ε2 or ε4 alleles 3, 5