Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline

Abstract

Lumbar puncture (LP) is an important and frequently performed invasive procedure for the diagnosis and management of neurological conditions. There is little in the neurological literature on the topic of periprocedural management of antithrombotics in patients undergoing LP. Current practice is therefore largely extrapolated from guidelines produced by anaesthetic bodies on neuraxial anaesthesia, haematology groups advising on periprocedural management of antiplatelet agents and anticoagulants, and by neuroradiology on imaging-guided spinal procedures. This paper summarises the existing literature on the topic and offers recommendations to guide periprocedural antithrombotic management for LP, based on the consolidation of the best available evidence. ​.

Clinical Progress Note: Consolidated Guidelines on Management of Coagulopathy and Antithrombotic Agents for Common Bedside Procedures

“…The decision to use bridging therapy prior to a bedside procedure must be individualized and take into account After 4 h (after 24 h if traumatic) 7 After 12-24 h 9 After 24-72 h 3…”

“…In the case of LP, we included some regional anesthesia and pain procedure guidelines based on the assumption that certain procedures are analogous to LP and associated with similar bleeding risks. Some of the guidelines referenced do After 6 h 7,8 After 24 h 4,9 After 48-72 h 3,11 Apixaban Continue 2,3f,10 ≥24 h 5c,11d 24-48 h 3g ≥48 h 11c…”

“…After 6 h 3 Next day 11d After 48-72 h 11c Continue 2 24 h (5 mg/d dose) 7 24-48 h (20 mg/d dose) 7 24-48 h 3 ≥48 h 11 72 h 8,9 After 6 h 8 After 6 h (5 mg/d dose) 7 After 6-24 h (20 mg/d dose) 7 After 24 h 9 After 48-72 h 3,11 a For patients with clinically significant renal dysfunction, please see individual references for periprocedural hold and restart times. e Patient-specific bleeding risk factors include, but are not limited to, hypertension, abnormal renal function, abnormal hepatic function, prior stroke, history of major bleeding (especially within the preceding 3 months), and bleeding history with a similar procedure.…”

“…2 The Association of British Neurologists (ABN), however, allows platelets to be 40,000/µL or greater than 20,000/µL with an additional risk-benefit discussion. 7 In contrast to paracentesis and thoracentesis, recommendations regarding hold times of antithrombotic medications prior to LP are more variable and sometimes more conservative. For example, some guidelines indicate that the thienopyridines can be continued, whereas others recommend holding them for up to 1 week prior to LP.…”

Management of bleeding and procedures in patients on antiplatelet therapy

“…Spinal haematoma is a rare but potentially devastating complication of neuraxial procedures with a reported incidence of anywhere between 1/1300-1/200,000 procedures (98). Risk factors for spinal haematoma include female gender, advanced age, wider gauge needles/catheters (incidence is higher for epidural than spinal anaesthesia), a history of excessive bleeding or bruising, multiple needle passes, and pre-existing bone disease such as osteoporosis (99,100).…”