Optimal Antithrombotic Therapy for Hemorrhagic Transformation with Intracranial Stenosis

Immediate Management of Active Hemorrhage

All antiplatelet agents must be discontinued immediately when intracranial hemorrhage is present or suspected, as recommended by the Neurocritical Care Society and Society of Critical Care Medicine 1, 2, 3, 4
If the patient was on dual antiplatelet therapy (aspirin plus clopidogrel), both agents should be stopped 1, 2
Platelet transfusion is NOT recommended for antiplatelet-associated intracranial hemorrhage in patients who will not undergo neurosurgical procedures, regardless of hemorrhage volume or neurologic examination 1, 2, 3, 4
If neurosurgical intervention is required, platelet transfusion may be considered for aspirin- or ADP inhibitor-associated hemorrhage, ideally with platelet function testing prior to transfusion 1, 2, 3, 4
One single donor apheresis unit of platelets is the suggested initial dose if transfusion is deemed necessary 3, 4

For patients with moderate to high-grade intracranial atherosclerotic stenosis (50-99%), aspirin 325 mg daily is recommended over oral anticoagulation, as per the World Stroke Organization guidelines 5
Single antiplatelet therapy (SAPT) is the appropriate choice rather than dual antiplatelet therapy (DAPT) in this specific context of prior hemorrhagic transformation 5
Anticoagulants are not recommended for intracranial stenosis unless there is another indication (e.g., atrial fibrillation) 5

Systolic blood pressure target <140 mmHg is recommended for patients with intracranial atherosclerotic stenosis 5
High-dose statin therapy is recommended regardless of baseline lipid levels 5
At least moderate physical activity should be encouraged 5
Angioplasty and stenting is not recommended for this population; medical therapy is superior 5

Do not resume dual antiplatelet therapy in patients with prior hemorrhagic transformation, even if they have high-grade intracranial stenosis 5
Do not rush to resume antithrombotics before hemorrhage has stabilized on imaging, as premature resumption increases rebleeding risk 1, 2
Do not use anticoagulation for intracranial stenosis in the absence of another compelling indication like atrial fibrillation 5
Do not transfuse platelets empirically for antiplatelet-associated hemorrhage unless neurosurgical intervention is planned 1, 2, 3, 4