Ischemic Stroke Prevention After Intracerebral Hemorrhage

Purpose of ReviewSurvivors of intracerebral hemorrhage (ICH) are not only at risk for recurrent ICH but often also have vascular risk factors which predispose them to ischemic events. Therefore, clinicians must balance ischemic risk with hemorrhagic risk. This review focuses on ischemic stroke prevention in ICH survivors, particularly the use of antithrombotic medications and the management of hyperlipidemia and hypertension.Recent FindingsWhile previous randomized controlled trials (RCTs) of antithrombotic therapy in stroke prevention excluded survivors of ICH, recent RCTs such as SoSTART, APACHE-AF, and RESTART shed more light into safety and risks of using antithrombotic therapy. Additionally, new imaging biomarkers of increased recurrent ICH risk can help inform treatment choices.Recent data suggests that antiplatelet agents are generally safe in ICH survivors, but these should not be used without an indication. However, the use of anticoagulants may lead to higher rates of recurrent ICH (and higher mortality) in patients with both deep and lobar hemorrhages. Therefore, shared decision-making is paramount including individualized risk stratification and exploration of potential alternatives to antithrombotic therapy. Multiple additional RCTs are ongoing to study the safety of anticoagulation in this high-risk group.