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  • Does Usage of Platelet or DDAVP Prevent Progression of Traumatic Intracranial Hemorrhage in Patients on Anti-Platelet Medication?

    Final Number:

    George William Koutsouras; Amrit Chiluwal; Katherine Wagner MD; David E Ledoux MD; Omar S Bholat MD; Jamie S. Ullman MD, FACS

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Anti-platelet agents(APA) are some of the most commonly used medications in the general population. When these patients suffer traumatic brain injury resulting in an intracranial hemorrhage(ICH), there is a concern for hemorrhage expansion due to their depressed platelet function.(1-5) In post-traumatic ICH(PTICH), the degree of volume expansion with pre-injury APA use is not well delineated, as studies have shown variable results.(6-7) Current management may involve platelet and/or desmopressin administration; however, clear clinical evidence for their use is lacking.(3) In this study, we have explored the utility of prophylactic administration of platelet and desmopressin administration in preventing the expansion of PTICH.

    Methods: Medical and radiological records of patients who received treatment at North Shore University Hospital between January 2015-June 2016 for acute traumatic ICH were reviewed. Patients were included if they were on pre-injury APA (aspirin and/or Plavix), but not on anticoagulation therapy. Subjects must have received a non-contrast CT scan between 6-24 hours following the initial scan, without undergoing a surgical intervention between the two scans. The use of desmopressin and platelets was collected. Chi-square and ANOVA analysis were performed to calculate group and mean differences, respectively.

    Results: Of 131 subjects, 46.6% had at least two distinct regional hemorrhages and 28.2% were on dual-antiplatelet therapy. 55% received both desmopressin and platelet transfusion prior to follow up CT scan. On follow up, 83% had a stable or decreased hemorrhage, while 17% had an increased hemorrhage. After adjusting for type of APA used, there was no significant difference in hemorrhage progression when comparing subjects who received platelets and/or desmopressin to those who did not receive therapy(p>0.05).

    Conclusions: The prophylactic use of platelets and desmopressin does not seem to prevent the progression of acute PTICH in patients exposed to pre-injury APA. Therefore, judicious use of these agents is warranted in the acute management of PTICH.

    Patient Care: In our institution, there are no clear practice guidelines for the use of platelets or desmopressin in the setting of traumatic ICH and antiplatelet agent use. The decision to use them is often done in an ad hoc basis, and therefore, there is a clear need to study if platelet or DDAVP usage is of any benefit to patients with traumatic ICH and on antiplatelet agents. Our ultimate goal is to manage these patients in a more uniform and evidence-based manner. This study will serve as an important step towards that goal.

    Learning Objectives: To determine the difference between the rate of progression of traumatic intracranial hemorrhage between the group that received platelets and/or DDAVP than the group that did not.

    References: 1. Thompson BB, Bejot Y, Caso V, Castillo J, Christensen H, Flaherty ML, Foerch C, Ghandehari K, Giroud M, Greenberg SM, et al. Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review. Neurology 2010; 75:1333-42. 2. Jaben EA, Mulay SB, Stubbs JR. Reversing the effects of antiplatelet agents in the setting of intracranial hemorrhage: a look at the literature. J Intensive Care Med 2015; 30:3-7. 3. Beynon C, Hertle DN, Unterberg AW, Sakowitz OW. Clinical review: Traumatic brain injury in patients receiving antiplatelet medication. Crit Care 2012; 16:228. 4. Jones K, Sharp C, Mangram AJ, Dunn EL. The effects of preinjury clopidogrel use on older trauma patients with head injuries. Am J Surg 2006; 192:743-5. 5. Ohm C, Mina A, Howells G, Bair H, Bendick P. Effects of antiplatelet agents on outcomes for elderly patients with traumatic intracranial hemorrhage. J Trauma 2005; 58:518-22. 6. Sansing LH, Messe SR, Cucchiara BL, Cohen SN, Lyden PD, Kasner SE, Investigators C. Prior antiplatelet use does not affect hemorrhage growth or outcome after ICH. Neurology 2009; 72:1397-402. 7. Ducruet AF, Hickman ZL, Zacharia BE, Grobelny BT, DeRosa PA, Landes E, Lei S, Khandji J, Gutbrod S, Connolly ES, Jr. Impact of platelet transfusion on hematoma expansion in patients receiving antiplatelet agents before intracerebral hemorrhage. Neurol Res 2010; 32:706-10.

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