Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

Background: Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy. Methods: We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388. Findings: 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67–1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05–3·16, p<0·0001). Interpretation: Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice

Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016

© 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly recognised as global health priorities in view of the preventability of most injuries and the complex and expensive medical care they necessitate. We aimed to measure the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI from all causes of injury in every country, to describe how these measures have changed between 1990 and 2016, and to estimate the proportion of TBI and SCI cases caused by different types of injury. Methods: We used results from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016 to measure the global, regional, and national burden of TBI and SCI by age and sex. We measured the incidence and prevalence of all causes of injury requiring medical care in inpatient and outpatient records, literature studies, and survey data. By use of clinical record data, we estimated the proportion of each cause of injury that required medical care that would result in TBI or SCI being considered as the nature of injury. We used literature studies to establish standardised mortality ratios and applied differential equations to convert incidence to prevalence of long-term disability. Finally, we applied GBD disability weights to calculate YLDs. We used a Bayesian meta-regression tool for epidemiological modelling, used cause-specific mortality rates for non-fatal estimation, and adjusted our results for disability experienced with comorbid conditions. We also analysed results on the basis of the Socio-demographic Index, a compound measure of income per capita, education, and fertility. Findings: In 2016, there were 27·08 million (95% uncertainty interval [UI] 24·30–30·30 million) new cases of TBI and 0·93 million (0·78–1·16 million) new cases of SCI, with age-standardised incidence rates of 369 (331–412) per 100 000 population for TBI and 13 (11–16) per 100 000 for SCI. In 2016, the number of prevalent cases of TBI was 55·50 million (53·40–57·62 million) and of SCI was 27·04 million (24·98–30·15 million). From 1990 to 2016, the age-standardised prevalence of TBI increased by 8·4% (95% UI 7·7 to 9·2), whereas that of SCI did not change significantly (−0·2% [–2·1 to 2·7]). Age-standardised incidence rates increased by 3·6% (1·8 to 5·5) for TBI, but did not change significantly for SCI (−3·6% [–7·4 to 4·0]). TBI caused 8·1 million (95% UI 6·0–10·4 million) YLDs and SCI caused 9·5 million (6·7–12·4 million) YLDs in 2016, corresponding to age-standardised rates of 111 (82–141) per 100 000 for TBI and 130 (90–170) per 100 000 for SCI. Falls and road injuries were the leading causes of new cases of TBI and SCI in most regions. Interpretation: TBI and SCI constitute a considerable portion of the global injury burden and are caused primarily by falls and road injuries. The increase in incidence of TBI over time might continue in view of increases in population density, population ageing, and increasing use of motor vehicles, motorcycles, and bicycles. The number of individuals living with SCI is expected to increase in view of population growth, which is concerning because of the specialised care that people with SCI can require. Our study was limited by data sparsity in some regions, and it will be important to invest greater resources in collection of data for TBI and SCI to improve the accuracy of future assessments. Funding: Bill & Melinda Gates Foundation

Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial

Background: Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy.Methods: We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388.Findings: 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67–1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05–3·16,

Dimethyl fumarate in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome

Dimethyl fumarate in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome

Impact of Evidence‐Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study

Background The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence‐based processes of care for acute ischemic stroke ( AIS ) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke. Methods and Results Use of 8 AIS processes of care were considered: reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0–2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or “defect‐free” care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18–1.65) and better survival (odds ratio, 2.23; 95% CI , 1.62–3.09). Defect‐free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0–1) (odds ratio, 1.22; 95% CI , 1.04–1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates. Conclusions Use of evidence‐based care is associated with improved clinical outcome in AIS . Strategies are required to address regional variation in the use of proven AIS treatments. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique Identifier: NCT 02162017. </jats:sec

Impact of Evidence-Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study

Background-The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence-based processes of care for acute ischemic stroke (AIS) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke. Methods and Results-Use of 8 AIS processes of care were considered: reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0-2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or defect-free care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18-1.65) and better survival (odds ratio, 2.23; 95% CI, 1.62-3.09). Defect-free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0-1) (odds ratio, 1.22; 95% CI, 1.04-1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates. Conclusions-Use of evidence-based care is associated with improved clinical outcome in AIS. Strategies are required to address regional variation in the use of proven AIS treatments.National Health and Medical Research Council of AustraliaUniv New South Wales, Fac Med, George Inst Global Hlth, Sydney, NSW, AustraliaCtr Estudios Clin, Inst Ciencias & Innovac Med, Santiago, ChileClin Alemana Univ Desarrollo, Fac Med, Serv Neurol, Dept Neurol & Psiquiatria, Santiago, ChilePeking Univ, Hlth Sci Ctr, George Inst Global Hlth, Beijing, Peoples R ChinaAustralian Catholic Univ, Nursing Res Inst, St Vincents Hlth Australia Sydney, Sydney, NSW, AustraliaUniv Cent Lancashire, Fac Hlth & Wellbeing, Preston, Lancs, EnglandUniv Chile, Fac Med, Dept Ciencias Neurol, Santiago, ChileUniv Sao Paulo, Ribeirao Preto Med Sch, Stroke Serv Neurol Div, Ribeirao Preto, BrazilFukuoka Univ, Fac Med, Dept Prevent Med & Publ Hlth, Fukuoka, Fukuoka, JapanUniv Leicester, Dept Cardiovasc Sci, Leicester Biomed Res Ctr, Leicester, Leics, EnglandUniv Leicester, Natl Inst Hlth Res, Leicester Biomed Res Ctr, Leicester, Leics, EnglandUniv Edinburgh, Ctr Clin Brain Sci, Edinburgh, Midlothian, ScotlandGeorge Inst Global Hlth, Sydney, NSW, AustraliaUniv Desarrollo, Serv Neurol, Dept Neurol & Psiquiatria Clin Alemana Santiago, Santiago, ChileSt Vincents Hlth Australia Sydney, Sydney, NSW, AustraliaAustralian Catholic Univ, Sydney, NSW, AustraliaUniv Cent Lancashire, Stroke Practice Res Unit, Sch Hlth, Lancashire Clin Trials Unit, Preston, Lancs, EnglandUniv Leicester, Dept Cardiovasc Sci, Cardiovasc Res Ctr, British Heart Fdn, Leicester, Leics, EnglandUniv Kelaniya, Dept Pharmacol, Fac Med, Colombo, Sri LankaChristian Med Coll & Hosp, Dept Neurol, Ludhiana, IndiaKaohsiung Med Univ & Hosp, Dept Neurol, Kaohsiung, TaiwanLinkou Chang Gung Mem Hosp, Dept Neurol, Taipei, TaiwanPeking Union Med Coll Hosp, Beijing, Peoples R ChinaUniv Sao Paulo, Ribeirao Preto Sch Med, Ribeirao Preto, BrazilMonash Univ, Dept Epidemiol & Prevent Med, Melbourne, Vic, AustraliaUniv Cent Lancashire, Sch Hlth Sci, Coll Hlth & Wellbeing, Preston, Lancs, EnglandUniv Desarrollo, Santiago, ChileUniv New South Wales, Neurosci Res Australia, Sydney, NSW, AustraliaNatl Univ Singapore, Dept Pharmacol, Singapore, SingaporeBradford Royal Infirm, Bradford Inst Hlth Res, Leeds, W Yorkshire, EnglandChristian Med College, Ludhiana, Punjab, IndiaRemediumOne Pvt Ltd, Kandy, Sri LankaKaohsiung Med Univ, Chung Ho Mem Hosp, Kaohsiung, TaiwanCalvary Publ Hosp Bruce, Bruce, AustraliaRoyal North Shore Hosp, St Leonards, NSW, AustraliaRoyal Prince Alfred Hosp, Camperdown, NSW, AustraliaConcord Repatriat Gen Hosp, Camperdown, NSW, AustraliaFiona Stanley Hosp, Camperdown, NSW, AustraliaMacquarie Base Hosp, Melbourne, Vic, AustraliaUniv Sao Paulo, Fac Med Ribeirao Preto, Hosp Clin, Sao Paulo, BrazilHosp Governador Celso Ramos, Florianopolis, SC, BrazilSao Paulo State Univ, Hosp Fac Med Botucatu, UNESP, Sao Paulo, BrazilYangquan Coalmine Grp Gen Hosp, Yangquan, Peoples R ChinaNanjing Med Univ, Nanjing Hosp 1, Nanjing, Jiangsu, Peoples R China85 Hosp Peoples Liberat Army, Beijing, Peoples R ChinaChifeng Univ, Affiliated Hosp, Chifeng, Peoples R ChinaBeijing Pinggu Hosp, Beijing, Peoples R ChinaWenzhou Med Univ, Affiliated Hosp 1, Wenzhou, Peoples R ChinaSoochow Univ, Affiliated Hosp 2, Suzhou, Peoples R ChinaHebei Med Univ, Hosp 3, Shijiazhuang, Hebei, Peoples R ChinaCapital Med Univ, Xuanwu Hosp, Beijing, Peoples R ChinaJining Med Univ, Affiliated Hosp, Jining, Peoples R ChinaThird Peoples Hosp Huizhou, Huizhou, Peoples R ChinaSecond Cangzhou Cent Hosp, Cangzhou, Peoples R ChinaShanghai Jiao Tong Univ, Hosp Affiliated, Sch Med, Shanghai, Peoples R ChinaBaogang Hosp, Baotou, Peoples R ChinaHarbin Med Univ, Affiliated Hosp 1, Harbin, Heilongjiang, Peoples R ChinaShanghai Jiao Tong Univ Sch, Tong Ren Hosp, Peoples Hosp Hejian City, Shanghai, Peoples R ChinaPeking Univ, Shougang Hosp, Beijing, Peoples R ChinaGuangzhou Med Univ, Affiliated Hosp 3, Guangzhou, Guangdong, Peoples R ChinaSecond Hosp Nanchang, Nanchang, Jiangxi, Peoples R ChinaBethune Int Peace Hosp, Beijing, Peoples R ChinaHua Henan Prov Peoples Hosp, Beijing, Peoples R ChinaHua Henan Prov Peoples Hosp, Zhengzhou, Henan, Peoples R ChinaShanghai Jiao Tong Univ, Sch Med, Shanghai Ninth Peoples Hosp, Shanghai, Peoples R ChinaShijiazhuang Cent Hosp, Shijiazhuang, Hebei, Peoples R ChinaHosp Base San Jos de Osorno, Osorno, ChileChristian Med Coll & Hosp, Ludhiana, Punjab, IndiaUnit Narayana Hrudayalaya Ltd, Mazumdar Shaw Med Ctr, Bangalore, Karnataka, IndiaDr Ramesh Cardiac & Multispecial Hosp Pvt Ltd, Guntur, IndiaPost Grad Inst Med Educ & Res, Chandigarh, IndiaBaby Mem Hosp Ltd, Calicut, Kerala, IndiaSree Chitra Tirunal Inst Med Sci & Technol, Thiruvananthapuram, Kerala, IndiaSri Jayawardenepura Gen Hosp, Sri Jayawardenepura Kott, Sri LankaColombo North Teaching Hosp, Colombo, Sri LankaColombo South Coching Hosp, Colombo, Sri LankaLinkou Chang Gung Mem Hosp, Taoyuan, TaiwanTaipei Med Univ, Shuang Ho Hosp, Taipei, TaiwanEn Chu Kong Hosp, New Taipei, TaiwanNatl Cheng Kung Univ Hosp, Tainan, TaiwanQueen Alexandra Hosp, Portsmouth, Hants, EnglandPortsmouth Hosp NHS Natl Hlth Serv iTrust, Portsmouth, Hants, EnglandUniv Coll London Hosp NHS Fdn Trust, London, EnglandUniv Hosp Birmingham NHS Fdn Trust, Queen Elizabeth Hosp Birmingham, Birmingham, W Midlands, EnglandSouthend Univ Hosp NHS Fdn Trust, Southend On Sea, EnglandKings Coll Hosp London, London, EnglandYork Teaching Hosp NHS Fdn Trust, York, N Yorkshire, EnglandNottingham Univ Hosp NHS Trust, Nottingham, EnglandBlackpool Teaching Hosp NHS Fdn Trust, Blackpool, EnglandGloucestershire Hosp NHS Fdn Trust, Gloucestershire Royal Hosp, Gloucester, EnglandTeaching Hospi NHS Fdn Trust, London, EnglandRoyal Cornwall Hosp NHS Trust, Truro, EnglandRoyal London Hosp, Barts Hlth NHS Trust, London, EnglandSheffield Teaching Hosp NHS Fdn Trust, Sheffield, S Yorkshire, EnglandCambridge Univ Hosp NHS Fdn Trust, Addenbrookes Hosp, Cambridge, EnglandRoyal Victoria Hosp, Belfast Hlth & Social Care Trust, London, EnglandPinderfields Gen Hosp, Mid Yorkshire Hosp NHS Trust, Wakefield, EnglandRoyal Devon & Exeter NHS Fdn Trust, London, EnglandBradford Teaching Hosp NHS Fdn Trust, Bradford, W Yorkshire, EnglandGreat Western Hosp NHS Fdn Trust, Swindon, Wilts, EnglandWatford Dist Gen Hosp, Watford, EnglandImperial Coll Healthcare NHS Trust, London, EnglandMedway NHS Fdn Trust, Gillingham, EnglandRoyal Liverpool & Broadgreen Univ NHS Trust, Liverpool, Merseyside, EnglandCalderdale & Huddersfield NHS Fdn Trust, Huddersfield, W Yorkshire, EnglandHywel Dda Univ Hlth Board, Haverfordwest, WalesChesterfield Royal Hosp NHS Fdn Trust, Calow, EnglandLuton & Dunstable Univ Hosp NHS Fdn Trust, Luton, Beds, EnglandCountess Chester Hosp NHS Fdn Trust, Chester, Cheshire, EnglandPeterborough City Hosp, Peterborough, Cambs, EnglandUniv Hosp Leicester NHS Trust, Leicester Royal Infirm, Leicester, Leics, EnglandDist Hosp NHS Fdn Trust, London, EnglandBarnsley Hosp NHS Fdn Trust, Barnsley, EnglandDorset Cty Hosp NHS Fdn Trust, Dorchester, EnglandRoyal Bournemouth & Christchurch Hosp NHS Fdn Tru, Royal Bournemouth Hosp, Bournemouth, Dorset, EnglandSouthern Hlth & Social Care Trust, Craigavon Area Hosp, Portadown, EnglandUnited Lincolnshire Hosp NHS Trust, Pilgrim Hosp, Lincoln, EnglandBedford Hosp NHS Trust, Bedford, EnglandSao Paulo State Univ, Hosp Fac Med Botucatu, UNESP, Sao Paulo, BrazilNational Health and Medical Research Council of Australia: 106696

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases:subgroup analyses of the RESTART randomised, open-label trial

Background: Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy. Methods: RESTART was a prospective, randomised, open-label, blinded-endpoint, parallel-group trial at 122 hospitals in the UK that assessed whether starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. For this prespecified subgroup analysis, consultant neuroradiologists masked to treatment allocation reviewed brain CT or MRI scans performed before randomisation to confirm participant eligibility and rate features of the intracerebral haemorrhage and surrounding brain. We followed participants for primary (recurrent symptomatic intracerebral haemorrhage) and secondary (ischaemic stroke) outcomes for up to 5 years (reported elsewhere). For this report, we analysed eligible participants with intracerebral haemorrhage according to their treatment allocation in primary subgroup analyses of cerebral microbleeds on MRI and in exploratory subgroup analyses of other features on CT or MRI. The trial is registered with the ISRCTN registry, number ISRCTN71907627. Findings: Between May 22, 2013, and May 31, 2018, 537 participants were enrolled, of whom 525 (98%) had intracerebral haemorrhage: 507 (97%) were diagnosed on CT (252 assigned to start antiplatelet therapy and 255 assigned to avoid antiplatelet therapy, of whom one withdrew and was not analysed) and 254 (48%) underwent the required brain MRI protocol (122 in the start antiplatelet therapy group and 132 in the avoid antiplatelet therapy group). There were no clinically or statistically significant hazards of antiplatelet therapy on recurrent intracerebral haemorrhage in primary subgroup analyses of cerebral microbleed presence (2 or more) versus absence (0 or 1) (adjusted hazard ratio [HR] 0·30 [95% CI 0·08–1·13] vs 0·77 [0·13–4·61]; pinteraction=0·41), cerebral microbleed number 0–1 versus 2–4 versus 5 or more (HR 0·77 [0·13–4·62] vs 0·32 [0·03–3·66] vs 0·33 [0·07–1·60]; pinteraction=0·75), or cerebral microbleed strictly lobar versus other location (HR 0·52 [0·004–6·79] vs 0·37 [0·09–1·28]; pinteraction=0·85). There was no evidence of heterogeneity in the effects of antiplatelet therapy in any exploratory subgroup analyses (all pinteraction&gt;0·05). Interpretation: Our findings exclude all but a very modest harmful effect of antiplatelet therapy on recurrent intracerebral haemorrhage in the presence of cerebral microbleeds. Further randomised trials are needed to replicate these findings and investigate them with greater precision. Funding: British Heart Foundation