Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage

CNS Neurosci Ther. 2023 Jun;29(6):1484-1496. doi: 10.1111/cns.14175. Epub 2023 Mar 21.


Objective: Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long-term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown.

Methods: We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included "antiplatelet," "intracerebral hemorrhage," "cerebral microbleeds," "hematoma expansion," "recurrent," and "reinitiate." Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed.

Results: When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients' concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case-by-case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence-based medicine evidence is needed in the future.

Conclusion: This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large-scale randomized controlled trials are required.

Keywords: antiplatelet drugs; antiplatelet therapy; hematoma expansion; intracerebral hemorrhage; recurrent ICH.

Publication types

  • Review
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cerebral Hemorrhage / diagnostic imaging
  • Cerebral Hemorrhage / drug therapy
  • Cerebral Hemorrhage / epidemiology
  • Humans
  • Incidence
  • Ischemic Stroke* / drug therapy
  • Platelet Aggregation Inhibitors / therapeutic use
  • Prognosis
  • Stroke* / complications


  • Platelet Aggregation Inhibitors