Analyzing Effect of Antiplatelets on Stroke After Intracerebral Hemorrhage in High-Risk Recurrence Group
Mausaminben Hathidara, MD
Al-Shahi Salman R, Minks DP, Rodrigues MA, Bhatnagar P, du Plessis JC, Joshi Y, et al. Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial. Lancet Neurol. 2019;18:643-652.
Due to high prevalence of vascular diseases, almost one-third of adults in high-income countries are taking antithrombotic (antiplatelet or anticoagulation). Whether it is beneficial to restart antiplatelet after spontaneous intracerebral hemorrhage (ICH) to prevent another vascular occlusive disease such as stroke, myocardial infarction, or peripheral arterial disease is a dilemma to clinicians due to fear of recurrence of ICH. To date, our knowledge to weigh risk and benefits in this situation is derived from observational and retrospective studies. Recently published, RESTART1 was the first prospective, randomized, open-label and blinded end point trial showing evidence that the risk of recurrent intracerebral hemorrhage was very small against the benefit of antiplatelets for secondary prevention. However, some of the sub-groups such as lobar hemorrhage and presence of cerebral microbleed have higher risk of recurrence intracerebral hemorrhage per observational studies,2,3,4 and whether the benefit still exceeds the risk amongst them is unclear.
The sub-group analysis performed by Dr. Al-Shahi Salman et al. recruited patients >18 years with spontaneous intracerebral hemorrhage who were already on antiplatelet or anticoagulation at the time of hemorrhage and after which therapy was discontinued. 537 participants were enrolled, of whom 525 (98%) had intracerebral hemorrhage: 507 (97%) were diagnosed on CT (252 assigned to start antiplatelet therapy and 255 assigned to avoid antiplatelet therapy), and 254 (48%) underwent the required brain MRI protocol (122 in the start antiplatelet therapy group and 132 in the avoid antiplatelet therapy group). Participants were followed for a median of 2 years to look for primary outcome as recurrence of intracerebral hemorrhage and secondary outcome of vascular occlusive events.