Lumbar puncture in patients using anticoagulants and antiplatelet agents

Abstract

The use of anticoagulants and antiplatelet agents has largely increased. Diagnostic lumbar puncture in patients taking these drugs represents a challenge considering the opposing risks of bleeding and thrombotic complications. To date there are no controlled trials, specific guidelines, nor clear recommendations in this area. In the present review we make some recommendations about lumbar puncture in patients using these drugs. Our recommendations take into consideration the pharmacology of these drugs, the thrombotic risk according to the underlying disease, and the urgency in cerebrospinal fluid analysis. Evaluating such information and a rigorous monitoring of neurological symptoms after lumbar puncture are crucial to minimize the risk of hemorrhage associated neurological deficits. An individualized patient decision-making and an effective communication between the assistant physician and the responsible for conducting the lumbar puncture are essential to minimize potential risks.

S1 guidelines “lumbar puncture and cerebrospinal fluid analysis” (abridged and translated version)

“…For the use of NOAK (new oral [or non-vitamin K-dependent] anticoagulants) such as dabigatran, rivaroxaban, apixaban, and edoxaban for the prophylaxis or therapy of thromboembolic events no systematic studies are available. Initial recommendations [ 39 ] consider emergency punctures under therapy in vital indications. Elective punctures of the CSF space should be carried out - if medically justifiable - after interrupting the NOAK according to the respective half-life, considering renal function, in particular for dabigatran (usually 2-3 days, for dabigatran and GFR [glomerular filtration rate] below 50 ml/min > 3 days).…”

“…Approval was granted in the first half of 2019 in Germany. If discontinuation of NOAK is associated with increased thromboembolic risk, conversion to heparin (bridging) is recommended [ 39 , 111 ].…”

Comparison of elevated phosphorylated neurofilament heavy chains in serum and cerebrospinal fluid of patients with amyotrophic lateral sclerosis

“…Recently, we and others described phosphorylated neurofilament heavy chain (pNfH) in cerebrospinal fluid (CSF) as a diagnostic biomarker for ALS 9–11. However, obtaining CSF by lumbar puncture (LP) can be a limiting factor due to the invasiveness and contraindications such as the use of anticoagulants 12. Therefore, a blood-based biomarker, which can be obtained by a simple venipuncture, would be a valuable alternative if the same diagnostic performance is achieved.…”

Clinical Perspective on Primary Angiitis of the Central Nervous System in Childhood (cPACNS)

“…Before anticoagulation or platelet inhibition is commenced, the indication for lumbar puncture should be evaluated as antiplatelet and anticoagulant drugs increase the risk of hemorrhagic complication, for example, spinal hematoma (83).…”