A systematic review and meta-analysis of traumatic intracranial hemorrhage in patients taking prehospital antiplatelet therapy: Is there a role for platelet transfusions?

Abstract

BACKGROUND Platelet transfusion has been utilized to reverse platelet dysfunction in patients on preinjury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication. METHODS Controlled, observational and randomized, prospective and retrospective studies describing tICH, preinjury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression. RESULTS Twelve of 18,609 screened references were applicable to our questions and were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.76–2.18; p = 0.346; I 2 = 32.5%). There was no significant reduction in hemorrhage progression (OR, 0.88; 95% CI, 0.34–2.28; p = 0.788; I 2 = 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR, 1.00; 95% CI, 0.53–1.90, p = 0.996; I 2 = 59.1%; p = 0.032). CONCLUSION Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets, highlighting the need for a prospective evaluation of this practice. LEVEL OF EVIDENCE Systematic Reviews and Meta-Analyses, Level III.

Eastern Association for the Surgery of Trauma Multicenter Trial: Comparison of pre-injury antithrombotic use and reversal strategies among severe traumatic brain injury patients

“…Of note, three studies showed evidence of harm. Similarly, Alvikas and colleagues 16 reported that the current evidence does not support platelet transfusion among APA with traumatic ICH. In our study, a small minority (9.6%) of APA patients received platelet transfusion, suggesting improved evidence dissemination.…”

Rapid detection of platelet inhibition and dysfunction in traumatic brain injury: A prospective observational study

“…Lastly, it is essential to also investigate the impact of platelet transfusion on TBI patient outcomes in a randomized controlled trial, as a recent review of the evidence suggests that this therapy may have limited benefit. 20 In addition, we believe that development of new platelet function tests is urgently needed to improve patient outcomes. These tests should focus on specific aspects of platelet functionality that go beyond platelet aggregation ex vivo, with particular attention to the more recently discovered platelet functions, such as interactions with other blood cells, as well as proinflammatory signaling.…”

Controversies and evidence gaps in the early management of severe traumatic brain injury: back to the ABCs

“…62 Although knowledge of antithrombotics and their reversal strategies is essential, the true benefit of these strategies is unclear (see online supplemental table 3). [85][86][87] For patients taking antiplatelets, platelet transfusion may be associated with higher mortality (OR 1.29; 95% CI 0.76 to 2.18), and it has no significant effect on PHI (OR 0.88; 95% CI 0.34 to 2.28) or need for neurosurgical intervention (OR 1.00; 95% CI 0.53 to 1.90). The effect on PHI was similar even when guided by platelet function assays.…”