Should a patient with primary intracerebral haemorrhage receive antiplatelet or anticoagulant therapy?

Introduction

Patients with primary intracranial haemorrhage may have risk factors for future thromboembolic events. Such a situation presents a therapeutic dilemma, as illustrated by the following case. A 55 year old man was admitted with right sided weakness. His history included hypertension that was difficult to control, type 2 diabetes, angina, and hyperlipidaemia. He had also had a minor stroke affecting his right side about 10 years previously. He was taking medication: aspirin 75 mg, atorvastatin 10 mg, bendroflumethiazide 2.5 mg, ramipril 2.5 mg, amlodipine 5 mg, isosorbide mononitrate modified release 60 mg, pioglitazone 15 mg (all once a day); hydralazine 50 mg twice a day; and metformin 850 mg and methyldopa 250 mg three times a day. He had smoked 20-30 cigarettes a day most of his adult life until 10 yeas previously, and he drank alcohol in moderation.

Examination confirmed grade 4/5 weakness of his right arm and leg and dysarthria. He was rather obese, with a body mass index of 36. Blood pressure on admission was 200/125 mm Hg, which settled very quickly, however, at about 140/80 mm Hg once the dose of amlodipine was increased to 10 mg once daily.

Electrocardiography showed sinus rhythm and mild left ventricular hypertrophy (voltage criteria). A computed tomogram of the head about 90 hours after the onset of symptoms showed a deep left basal ganglia haematoma (fig 1).

Should he resume his antiplatelet therapy?

This case raised an important question which is often ignored in practice. Should a patient who seems to have a high thromboembolic risk but is recovering from a potentially fatal intracranial haemorrhage receive antiplatelet agents to prevent future ischaemic (cerebrovascular and other vascular) events? Is there any evidence in favour of or against such therapy?