Article Commentary: “Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial”
Pamela Cheng, DO
What to do after having a spontaneous intracerebral hemorrhage while on blood thinners? Prior to RESTART, there were no published randomized controlled trials testing the safety or benefit of resuming long-term antithrombotic therapy in survivors of intracerebral hemorrhage. Previous secondary stroke prevention trials showed a favorable benefit of antithrombotic therapy, but these trials excluded patients with history of intracerebral hemorrhage. RESTART was thus initiated with the aim of establishing whether starting versus avoiding antiplatelet therapy had any effect on recurrent symptomatic intracerebral hemorrhage and whether this risk of bleeding would exceed the benefit of reduction of vascular events.
RESTART was an investigator-led, pragmatic, multi-center, prospective, randomized, open-label, blinded endpoint, parallel-group trial in 122 hospitals in the United Kingdom. Inclusion criteria were adults older than 18 years of age who had survived at least 24 hours of spontaneous intracerebral hemorrhage while on either anticoagulant or antiplatelet therapy. Exclusion criteria included hemorrhage related to trauma, hemorrhagic transformation of an ischemic stroke, intracranial hemorrhage without intracerebral hemorrhage, or if they were pregnant, breastfeeding, or of childbearing age. Intervention arm was restricted to use of either oral aspirin, dipyridamole, or clopidogrel, begun within 24 hours of randomization.