Aspirin-Associated Intracerebral Hemorrhage: Risk Factors and Management

Introduction

Antiplatelet agents reduce the incidence of serious vascular events, such as myocardial infarction, stroke, and vascular death, by about one-quarter in high-risk patients.1 Among the agents, aspirin is the most commonly recommended drug for the prevention or recurrence of ischemic strokes, except for cardioembolic infarction.2 Aspirin also decreases the relative risk (RR) of vascular events by 12–14% in primary prevention.3 Aspirin therapy is associated with a 17% reduction in stroke (odds ratio [OR] 0.83, 95% confidence interval [CI], 0.70–0.97; P=0.02) in women, although there is no significant effect on stroke in men. However, aspirin therapy is associated with an increased risk of bleeding, such as intracerebral hemorrhage (ICH), in both primary and secondary prevention trials.1, 3 In general, hemorrhagic stroke results in more severe neurological deficits and higher mortality than ischemic stroke.4 Recently, concern has grown about hemorrhagic stroke because of widespread use of antithrombotic therapy.5, 6 Therefore, physicians should pay attention to the possible occurrence of hemorrhagic stroke in patients taking aspirin. This review will summarize the epidemiology, risk factors, clinical and neuroradiological features, and management of aspirin-associated ICH.

Abstract

Aspirin therapy has been shown to be associated with an increased risk of bleeding, such as intracerebral hemorrhage (ICH), in both primary and secondary prevention trials. Suggested risk factors for aspirin-associated ICH are advanced age, Asian or African American ethnicity, head trauma, epistaxis, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, cerebral amyloid angiopathy, combination antiplatelet therapy, concurrent anticoagulation, and presence of cerebral microbleeds on brain magnetic resonance imaging. Aspirin-associated ICH is associated with lobar or cerebellar location, increased hematoma growth, and increased mortality, compared with ICH that occurs without antiplatelet therapy. Currently, there are no specific clinical guidelines for management of aspirin-associated ICH. Patients should be managed according to clinical guidelines for management of spontaneous ICH. Physicians should always consider both the benefits and the risks of using aspirin for patients with risk factors for the development of ICH.

Keywords

aspirin, intracerebral hemorrhages, risk factors