Restarting Aspirin After a Bleed in a Man Whose Stent Still Needs It
A retired mail carrier's brain bleed has stopped growing, but the drug-eluting stent in his coronary artery hasn't stopped needing protection. Restarting aspirin and reversing the bleed are two different clocks running at the same time.
G.O., a 70-year-old retired mail carrier, had a drug-eluting stent placed fourteen months ago after a heart attack he still describes as coming “out of nowhere” on an ordinary route day, and has taken his daily aspirin without missing a dose since. A week ago, poorly controlled hypertension caught up with him differently: a spontaneous left basal ganglia hemorrhage, aspirin held on admission, weakness on his right side that has only partially improved. His hemorrhage has now held stable across three separate scans — admission, 24 hours, and again at day 7 — the kind of consistent stability that answers the acute rebleeding-risk question about as clearly as imaging can. What it doesn't answer is the second clock running in the background: a drug-eluting stent that has gone a week without the antiplatelet therapy it was placed expecting to have indefinitely.
Al-Shahi Salman and colleagues' 2019 RESTART trial randomized patients on antiplatelet therapy who had survived an intracerebral hemorrhage to resuming or withholding that therapy, and found restarting was not associated with an increase in recurrent hemorrhage — if anything, the point estimate trended toward fewer recurrent hemorrhagic events in the group that restarted (adjusted hazard ratio 0.51, p=0.06). What it did not show was a reduction in major occlusive vascular events, which came out level between the two arms — so the case for resuming rests on antiplatelet therapy's benefit established elsewhere, with RESTART supplying the permission rather than the reason. The trial's population leaned toward lobar rather than deep hemorrhages, which is a real, worth-naming difference from his basal ganglia location — a directional match on the core safety question, not an exact population overlap, and one the team weighs alongside his own three-scan stability rather than treating RESTART's result as automatically transferable. Against that, an unprotected drug-eluting stent carries a documented, non-trivial stent-thrombosis risk that climbs the longer antiplatelet therapy stays withheld, a risk that has been accumulating every day since admission independent of anything his brain imaging shows. His right-sided weakness, while only partially improved, has continued its slow trajectory of recovery through the week, which the team has noted as reassuring background but explicitly separate from today's antithrombotic decision — the two questions, motor recovery and stent protection, run on different timelines and shouldn't be allowed to blur into one another.
Two clocks, one decision
I want one more scan before we restart. RESTART's population was mostly lobar hemorrhages, and his is deep, basal ganglia — a different underlying vessel pathology, typically hypertensive small-vessel disease rather than amyloid angiopathy. I'm not saying the trial doesn't apply at all, but I don't think it maps onto his anatomy cleanly enough to skip one more day of confirmation.
That's a fair distinction to name, and I agree it's not an exact population match. But he's had three stable scans already, not one, and every day we wait is a day his stent goes unprotected — that risk doesn't pause while we wait for more reassurance on the bleed side. I'd rather act on the stability we've already confirmed three times than hold out for a fourth confirmation of the same finding.
One thing worth settling before we go further: whatever we decide, it should be full-dose aspirin resumption, not a reduced or tapered dose. RESTART tested standard-dose antiplatelet resumption, and a taper isn't a safer middle option — it's an untested one that offers less stent protection without any evidence it offers more bleeding safety. Given that, resuming today at his standard 81mg, on the strength of three consistent scans, is the option actually grounded in the trial we're citing.
Aspirin resumed at his standard dose on day 7. Repeat imaging at 48 hours after resumption showed no hemorrhage expansion, and cardiology confirmed no stent-related events through the remainder of his admission.
The vascular neurologist's anatomic concern was never disproven — basal ganglia hemorrhages genuinely do carry a different underlying mechanism than the lobar hemorrhages that made up most of RESTART's population — but the outcome here didn't distinguish between the two positions, since neither a bleed recurrence nor a stent event occurred to test them against each other.