Last reviewed: November 2017
Last updated: November  2017

Important updates

Landmark cohort study on long-term antiplatelet treatment use in over-75s (post MI/stroke/TIA) and risk of major GI bleeding

  • Older people receiving daily aspirin-based antiplatelet treatment without routine proton-pump inhibitor (PPI) use are at higher and more sustained risk of major bleeding than younger patients.

  • Half of the major bleeding events in patients ages 75 or older were upper gastrointestinal. The estimated numbers needed to treat for routine PPI use to prevent major upper gastrointestinal bleed were low. The authors concluded that co-prescription should be encouraged.

Original source of update



History and exam

Key diagnostic factors

  • neck stiffness
  • hx of atrial fibrillation
  • hx of liver disease
  • hx of hematologic disorder
  • visual changes
  • photophobia
  • sudden onset
  • altered sensation
  • vertigo
  • nausea/vomiting
  • headache
  • weakness
  • sensory loss
  • aphasia
  • dysarthria
  • ataxia
  • altered level of consciousness/coma
  • confusion
  • gaze paresis

Risk factors

  • advanced age
  • male sex
  • Asian, black and/or Hispanic
  • FHx of hemorrhagic stroke
  • hemophilia
  • cerebral amyloid angiopathy
  • autosomal dominant mutations in the COL4A1 gene
  • hereditary hemorrhagic telangiectasia
  • autosomal dominant mutations in the KRIT1 gene
  • autosomal dominant mutations in the CCM2 gene
  • autosomal dominant mutations in the PDCD10 gene
  • HTN
  • anticoagulation
  • illicit sympathomimetic drugs
  • vascular malformations
  • smoking
  • nonsteroidal anti-inflammatories (NSAIDs)
  • diabetes mellitus
  • heavy alcohol abuse
  • sympathomimetic medications
  • cerebral vasculitis
  • thrombocytopenia
  • Moyamoya disease
  • leukemia

Diagnostic investigations

1st investigations to order

  • non-infused head CT
  • chemistry panel
  • CBC
  • clotting tests
  • ECG
  • platelet function test
  • urine drug screen
  • pregnancy test in women of childbearing age
  • liver function test
  • intracerebral hemorrhage (ICH) score
Full details

Investigations to consider

  • CT angiography and venography
  • magnetic resonance angiography and venography
  • conventional (invasive) angiography
  • MRI brain with diffusion-weighted imaging (DWI) and gradient-echo sequence (GRE)
  • MRI brain with susceptibility-weighted imaging
Full details

Treatment algorithm


Authors VIEW ALL

Clinical Associate of Neurology

Medical Director, Neuroscience ICU

Director, Neurocritical Care Education

Co-Director, Stroke Center

University of Chicago




FDG declares that he has no competing interests.

Neurocritical Care Fellow

Department of Neurology

University of Chicago




RCM declares that she has no competing interests.

Dr Fernando Goldenberg and Dr Raisa Martinez would like to gratefully acknowledge Dr Alejandro Hornik, Dr Eric E. Smith, and Dr T. Dion Fung, the previous contributors to this monograph. EES is an author of a number of references cited in this monograph. AH and TDF declare that they have no competing interests.

Peer reviewers VIEW ALL

Lecturer in Neurology

Hospital Chief

Cerebrovascular/Stroke Division

Beth Israel Deaconess Medical Center

Division of Cerebrovascular/Stroke




LRC declares that he has no competing interests.

Neurology Registrar

Neurology Service

Centre Hospitalier Universitaire Vaudois (CHUV)




JM declares that he has no competing interests.

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