When do you restart antiplatelet therapy in patients with hemorrhagic conversion of stroke?

This is a great question and not an uncommon clinical encounter for stroke neurologists. Indeed there is no one right answer.

First, you may want to make sure that the observed ICH is true transformation of an ischemic lesion.

Second, the degree of hemorrhagic transformation matters, I totally agree, for HI 1 or even 2 low dose ASA can be started as soon as obtaining a stable follow-up CT. While higher grades might need 1-4 weeks waiting. Please note that the HI and PH gradings were developed based on CT scan findings (not MRI), a couple of decades ago.

Third, knowing the underlying mechanism matters. If you’re dealing with a septic emboli, for instance, the answer is never but if you’re dealing with ICAD with recurring stroke you may want ...

I would wait about one week, and if the patient is stable I would begin ASA.