Early antiplatelet therapy used for acute ischemic stroke and intracranial hemorrhage

Abstract

In this editorial we comment on the article published by Zhang et al in the recent issue of World Journal of Clinical Cases. We evaluate their claims on the benefit of use of Aspirin in the early management of patients with ischemic stroke. We also comment on their contention of using aspirin in the early management of patients with intracranial hemorrhage, a practice not seen in modern medicine. Large clinical trials such as the International Stroke Trial and the Chinese Acute Stroke Trial have shown the benefit of Aspirin use within 48 h of patients with Acute Ischemic Stroke. The findings were corroborated in the open-label trial performed by Zhang et al in a smaller sample group of 25 patients where they showed improvement in functional scores at 90 days without an increase in adverse events. As such, this intervention is also recommended by the American Heart Association stroke guidelines from 2021. With regard to Intracranial hemorrhage, traditional practice has been to discontinue or avoid antiplatelet therapy in these patient groups. However, no studies have been done to evaluate this management strategy that is more borne out of the mechanism behind Aspirin’s effect on the coagulation pathway. Zhang et al evaluate the benefits of Aspirin on patients with low-volume intracranial hemorrhage, i.e., less than 30 mL on computed tomography imaging, and show no increase in mortality. The caveat of this finding is that all outcomes were pooled into one group for results, and the number of patients was low. While more studies with larger patient groups are required, the data from Zhang et al suggests that patients with small-volume intracranial hemorrhages may benefit from Aspirin administration in the acute phase of management.

Keywords: Aspirin, Ischemic stroke, Intracranial hemorrhage, CVA, Antiplatelet therapy

Core Tip: Clinical trials continue to demonstrate the benefits of Aspirin when given within 48 h of patients with Acute Ischemic Stroke. However, while not standard practice, Aspirin may also have a benefit in patients with Acute Hemorrhagic Stroke with small volume of blood noted on imaging. As aspirin inhibits the coagulation pathway, it may improve blood flow to the ischemic areas surrounding the hemorrhage and improve outcomes without a concomitant increase in mortality.