Clinical Scenario: 78 yo M with hx of CAD and DM, presents with right sided weakness that started one hour prior to arrival, denies trauma. He is found to have an intracerebral hemorrhage on CT. As you go through his medication list, you notice that he is on antiplatelets. His home health aid at bedside says he takes all his medications daily and at baseline, he ambulates without assistance and feeds himself.
Question: Do you reverse the antiplatelet agent?
A 2010 clinical review in World of Neurosurgery by Campbell et al says “at present, the literature contains insufficient information to establish any guidelines or treatment recommendations. In light of this, the current authors have proposed a protocol for antiplatelet reversal in both spontaneous and traumatic acute ICH.”
That same year, Scott Weingart had a podcast with sample reversal guidelines in patients on antiplatelets with traumatic head bleeds, which included DDAVP and 1 donor pack platelets.
In 2013, Martin and Conlon had a Best Available Evidence article in Annals of Emergency Medicine which concluded that “there are no compelling data currently supporting the use of platelet transfusion in the management of patients with spontaneous or traumatic intracerebral hemorrhage who are receiving antiplatelet medications. It would be within the standard of care to withhold platelet transfusion in patients with either spontaneous or traumatic intracerebral hemorrhage who are receiving antiplatelet therapy.”
In 2016, the PATCH trial by Baharoglu et al was published. It was a randomized multicenter trial where 190 patients who were on antiplatelet therapy with nontraumatic intracerebral hemorrhage were either placed in standard care or standard care with platelet transfusion groups. The authors’ conclusion was that “platelet transfusion seems inferior to standard care for people taking antiplatelet therapy before intracerebral hemorrhage. Platelet transfusion cannot be recommended for this indication in clinical practice.”
Take home point: It is within standard of care to withhold platelets from these patients and a recent randomized trial showed potential harm with platelet transfusion in atraumatic intracerebral hemorrhage.
Want to read more?
http://www.annemergmed.com/article/S0196-0644(12)00295-8/abstract
https://emcrit.org/racc/reversal-head-bleeds/
http://www.emdocs.net/platelets-ddavp-management-intracranial-hemorrhage/
http://rebelem.com/patch-trial-hold-platelets-spontaneous-intracerebral-hemorrhage/
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30392-0/abstract
http://www.worldneurosurgery.org/article/S1878-8750(10)00232-9/fulltext