Aspirin Therapy After Intracerebral Hemorrhage

Primary Guideline Recommendations

The American Heart Association/American Stroke Association recommends that aspirin monotherapy can probably be restarted in the days after intracerebral hemorrhage (ICH) if indicated, although the optimal timing is uncertain (Class IIa; Level of Evidence B) 1
The American Heart Association/American Stroke Association suggests that antiplatelet monotherapy after any ICH might be considered, particularly when there are strong indications for these agents (Class IIb; Level of Evidence B) 1
For patients without mechanical heart valves, avoidance of oral anticoagulation for at least 4 weeks might decrease the risk of ICH recurrence (Class IIb; Level of Evidence B) 1
The World Stroke Organization recommends aspirin administration within 24-48 hours after ischemic stroke onset, but for those treated with IV thrombolysis, aspirin is generally delayed until >24 hours 2

Strong indications for aspirin therapy include recent acute coronary syndrome, coronary stents, high-risk coronary disease, or documented high thrombotic risk 1
Weaker indications for aspirin therapy include primary prevention, stable coronary disease without recent events 1
Risk factors for ICH recurrence include lobar location of the initial ICH, older age, presence and number of microbleeds on gradient echo MRI, and apolipoprotein E ε2 or ε4 alleles 1, 3

For non-lobar ICH with strong antiplatelet indication, aspirin can be restarted at 3-7 days post-ICH if clinically stable 1
For lobar ICH or moderate indication, aspirin should be restarted after a minimum of 4-6 weeks 1
For any ICH with mechanical heart valve, timing should be individualized with cardiology consultation, as anticoagulation may be needed much earlier 3