Emergency Reversal of Antiplatelet Agents in Patients Presenting with an Intracranial Hemorrhage: A Clinical Review

Campbell, Peter G.; Sen, Anish; Yadla, Sanjay; Jabbour, Pascal; Jallo, Jack

doi:10.1016/j.wneu.2010.05.030

Cited by 92 publications

(36 citation statements)

References 57 publications

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“…While the reversal of warfarin has been shown to reduce recurrence and improve outcome, 10,15 the reversal of antiplatelet agents with desmopressin or platelet transfusions is controversial and was not captured here. 5 Our sample sizes for newer anticoagulants, such as dabigatran or fondaparinux, were too limited to allow subgroup analyses of any antithrombotics other than ASA, warfarin, or clopidogrel. Our cohort size of 479 patients, while one of the largest series in the literature, remains too limited to allow a proper comparison of thromboembolic risk between patients with and without a history of AT.…”

mentioning

confidence: 99%

Timing of the resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: a retrospective cohort study

Guha

Coyne

Macdonald

2016

JNS

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C hroniC subdural hematoma (cSDH) is a disease of the elderly and demonstrates an incidence of approximately 3.4 patients per 100,000 persons younger than 65 years of age and 8 to 58 patients per 100,000 persons older than 65 years. 1,4,9 The prevalence of cSDH is expected to rise as the percentage of the United States population older than 65 years grows from 12% in 2003 to a projected 20% by 2030. 17Other identified risk factors for the development of cSDH include male sex, history of falls, chronic alcohol use, and antiplatelet or anticoagulant therapy, with warfarin increasing the relative risk of developing cSDH by aBBreViatiONS ADP = adenosine diphosphate; ASA = acetylsalicylic acid; AT = antithrombosis; CAD = coronary artery disease; cSDH = chronic subdural hematoma; DVT = deep venous thrombosis; INR = international normalized ratio; LMWH = low-molecular-weight heparin; TIA = transient ischemic attack. OBJectiVe Antithrombosis (AT), defined here as either antiplatelets or anticoagulants, is a significant risk factor for the development of chronic subdural hematomas (cSDHs). Resuming AT following the evacuation of cSDH is a highly variable practice, with scant evidence in the literature for guidance. Here, a retrospective analysis of a cohort of patients from a single institution undergoing surgical drainage of cSDH was performed to evaluate postoperative complications and determine the optimal timing of the resumption of common antithrombotic agents. methOdS This retrospective analysis was performed on 479 patients undergoing surgical evacuation of cSDH at St. Michael's Hospital over a 5-year period (2007)(2008)(2009)(2010)(2011)(2012). The collected variables included the type of AT agent, indications for AT, timing and type of postoperative complications, and the restart intervals for the AT agents, when available. Postoperative complications were classified as major hemorrhages, minor hemorrhages, or thromboembolic events. reSultS Among all 479 study patients, 71 experienced major hemorrhage (14.8%), 110 experienced minor hemorrhage (23.0%), and 8 experienced thromboembolism (1.67%) postoperatively. Patients on any type of preoperative AT regimen were at a higher risk of major hemorrhage (19.0% vs 10.9%; OR 1.93; 95% CI 1.15-2.71; p = 0.014). The type of AT agent did not affect the frequency of any postoperative complications. Patients on any preoperative AT regimen experienced earlier postoperative major hemorrhages (mean 16.2 vs 26.5 days; p = 0.052) and thromboembolic events (mean 2.7 vs 51.5 days; p = 0.036) than those patients without a history of AT; the type of AT agent did not affect timing of complications. Patients who were restarted on any AT therapy postoperatively were at decreased risk of major rebleeding following resumption than those patients who were not restarted (OR 0.06; 95% CI 0.02-0.2; p < 0.01). cONcluSiONS Patients with a history of preoperative AT experienced thromboembolic complications significantly earlier than those patients without AT, which peaked at 3 days postoperative...

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confidence: 99%

Timing of the resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: a retrospective cohort study

Guha

Coyne

Macdonald

2016

JNS

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“…The literature would suggest that there is no definitive reversal algorithm that has been established in the treatment of antiplatelet related intracranial hemorrhage [15] [26]- [28], but aggressive platelet transfusion empirically seems appropriate in this context. Ideally, outcomes in such patients with varying reversal protocols would be studied.…”

Section: Discussionmentioning

confidence: 99%

Premorbid Use of Clopidogrel Portends Worse Outcomes in Patients Treated Surgically for Intracranial Hemorrhage

Marvin¹,

Danison²,

Davis³

et al. 2014

OJMN

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Background: Widespread use of antiplatelet and anticoagulation medications (APACs) can be a difficult challenge in the presence of a neurosurgical emergency. Premorbid use of APACs, particularly clopidogrel, has been shown to affect outcomes in patients with stroke and traumatic brain injury. Objective: We hypothesized that pre-morbid clopidogrel use in patients with intracranial hemorrhage necessitating surgical intervention would lead to a greater risk of death and need for re-operation than those taking other APACs. Methods: Retrospective single institution review was conducted from January, 2010 through November, 2012 for intracranial hemorrhages necessitating surgical evacuation. Acute, subacute and chronic subdural, epidural and intraparenchymal hemorrhages were included. Results: 185 of 410 patients that required surgery for intracranial hemorrhage were on APACs. Overall mortality rate was 33%, with a 37% mortality rate in the APAC group. Overall reoperation rate was 7.5%, and 13%

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“…8,10,11,25,37,57,60,70 The risk for ICH appears to be dose dependent with aspirin, the most studied agent, but exists with other agents as well. 46 demonstrated that the chance of undergoing a craniotomy for ICH, when controlling for size of hemorrhage and location, was increased with pre-event aspirin use and platelet inhibition as determined by VerifyNow ASA.…”

Section: Antiplatelet-related Ichmentioning

confidence: 99%

“…These authors identified 635 studied patients in 5 retrospective reviews in which 3 studies revealed no benefit, 1 revealed higher mortality in the transfusion cohort, and 1 demonstrated decreased mortality with transfusion (although there were 92 patients in the transfusion arm and 19 in the no-transfusion arm). 47 Another literature review by Campbell et al 8 also found no clear evidence of benefit with platelet transfusion, but suggested the following protocol as a starting point for further investigation: 1) for a patient with ICH on aspirin alone, transfuse 1 pack of platelets; 2) for a patient with a small ICH on clopidogrel or a combination of therapies, administer 2 units of platelets; 3) for patients with large ICH on clopidogrel or multiple agents, administer desmopressin 3 mcg/kg intravenously and 1 pack of platelets every 12 hours for 48 hours. There is a randomized trial currently underway to evaluate antiplatelet agent reversal in ICH (Platelet Transfusion in Cerebral Hemorrhage [PATCH] trial).…”

Section: Antiplatelet-related Ichmentioning

confidence: 99%

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The role of anticoagulants, antiplatelet agents, and their reversal strategies in the management of intracerebral hemorrhage

James

Palys

Lomboy

et al. 2013

FOC

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New anticoagulant and antiplatelet medications have been approved and are prescribed with increased frequency. Intracranial hemorrhage is associated with the use of these medications. Therefore, neurosurgeons need to be aware of these new medications, how they are different from their predecessors, and the strategies for the urgent reversal of their effects. Utilization of intraluminal stents by endovascular neurosurgeons has resulted in the need to have a thorough understanding of antiplatelet agents. Increased use of dabigatran, rivaroxaban, and apixaban as oral anticoagulants for the treatment of atrial fibrillation and acute deep venous thrombosis has increased despite the lack of known antidotes to these medications.

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Emergency Reversal of Antiplatelet Agents in Patients Presenting with an Intracranial Hemorrhage: A Clinical Review

Cited by 92 publications

References 57 publications

Timing of the resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: a retrospective cohort study

Timing of the resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: a retrospective cohort study

Premorbid Use of Clopidogrel Portends Worse Outcomes in Patients Treated Surgically for Intracranial Hemorrhage

The role of anticoagulants, antiplatelet agents, and their reversal strategies in the management of intracerebral hemorrhage

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