What is the management approach for a patient with early hemorrhagic conversion after an intracranial hemorrhage (ICH) who is on aspirin (acetylsalicylic acid) for secondary prevention of cardiovascular events?

Management of Aspirin in Early Hemorrhagic Conversion After Ischemic Stroke

Immediately discontinue aspirin and avoid all antiplatelet agents when hemorrhagic conversion occurs after ischemic stroke, as aspirin administration in the setting of intracranial hemorrhage significantly increases mortality and hematoma expansion. 1

Immediate Actions Upon Detecting Hemorrhagic Conversion

• Stop aspirin immediately upon confirmation of hemorrhagic transformation on brain imaging, as aspirin worsens bleeding and increases mortality in patients with intracranial hemorrhage 1
• Do not administer platelet transfusion for aspirin reversal in hemorrhagic conversion, as randomized trial data demonstrate worse outcomes in patients with ICH receiving antiplatelet therapy who are treated with platelet infusion 2
• Achieve blood pressure control targeting systolic BP 130-150 mmHg using rapid-onset, short-acting agents to prevent hematoma expansion, which is the only modifiable predictor of ICH outcome 2

Evidence Supporting Aspirin Discontinuation

The evidence strongly supports immediate cessation of antiplatelet therapy in hemorrhagic conversion:

• Aspirin increases hemorrhagic transformation risk in ischemic stroke patients, with a small but significant absolute increase (0.1%) in intracranial hemorrhage 2
• Pre-existing aspirin use at ICH onset independently predicts mortality (RR 2.5,95% CI 1.3-4.6) and associates significantly with hematoma enlargement during the first week 3
• Aspirin combined with thrombolysis increases symptomatic intracranial hemorrhage risk (OR 3.73,95% CI 1.03-13.49) without providing early antithrombotic benefit 4

Critical Distinction: Hemorrhagic Conversion vs. Primary ICH

This question addresses hemorrhagic conversion in an ischemic stroke patient (ICVA = ischemic cerebrovascular accident), not primary ICH. The management differs from guidelines about restarting antiplatelet therapy after primary spontaneous ICH:

• For hemorrhagic conversion: Aspirin must be stopped immediately as the patient has acute intracranial bleeding 1
• For primary ICH survivors (different scenario): Guidelines suggest antiplatelet resumption may be reasonable beyond 24 hours in select patients with strong cardiovascular indications, based on RESTART trial data showing potential safety 2

Timing Considerations for Future Antiplatelet Therapy

Once the acute hemorrhagic conversion has stabilized, future antiplatelet decisions require careful assessment:

• Beyond 24 hours after ICH: In patients with spontaneous ICH and strong cardiovascular indications, restarting antiplatelet therapy may be considered based on individualized risk-benefit assessment 2
• Multiple international guidelines (US, Canada, China, UK/Ireland) provide Level B evidence that antiplatelet resumption after ICH may be reasonable in select patients with prior major adverse cardiovascular events 2
• The RESTART trial showed counterintuitively that antiplatelet agents might not increase recurrent ICH risk (adjusted HR 0.51,95% CI 0.25-1.03) in ICH survivors with prior antithrombotic use 2
• Recent meta-analysis demonstrates early antiplatelet resumption after ICH reduces recurrent hemorrhage by 46% (RR 0.54,95% CI 0.37-0.78) without increasing major complications 5

Common Pitfalls to Avoid

• Never continue aspirin during active intracranial hemorrhage, regardless of cardiovascular risk, as bleeding complications are immediately life-threatening 1
• Never use platelet transfusion to reverse aspirin in hemorrhagic stroke, as this worsens outcomes 2
• Do not restart aspirin within 24 hours of hemorrhagic conversion, even if the original indication was strong 2
• Avoid very aggressive blood pressure lowering below 130 mmHg systolic, as this may be harmful 2

Algorithm for Decision-Making

1. Confirm hemorrhagic conversion with brain imaging (CT or MRI) 1
2. Immediately discontinue aspirin and all antiplatelet agents 1
3. Stabilize blood pressure to 130-150 mmHg systolic 2
4. Do not give platelet transfusion 2
5. After 24+ hours of stability: Reassess cardiovascular risk versus recurrent hemorrhage risk for potential future antiplatelet therapy 2
6. If strong cardiovascular indication exists (recent MI, coronary stent, high MACE risk): Consider antiplatelet resumption only after hemorrhage stabilization, ideally with multidisciplinary consultation 2