1. The Management of Traumatic ICH in pateints Taking PreInjury Antiplatelet Agents
Mr Batchelor.
Consultant In Emergency Medicine
Central Manchester Foundation Trust

2. The Main Rational For Treatment Is to Preevnt Haematoma Expansion
The Management of Traumatic ICH in pateints Taking PreInjury Antiplatelet Agents
The Main Rational For Treatment Is to
Preevnt Haematoma Expansion

3. The Main Risk Factors For Haematoma
The Management of Traumatic ICH in pateints Taking PreInjury Antiplatelet Agents
The Main Risk Factors For Haematoma
Expansion are oral anticoagulants, specific bleeding diatheses, coagulopathy and size of the haematoma.

4. Fall From Standing Evidence of facial Bruising or scalp haematoma
Perform CT
Remember C spine
Standard practice at CMFT
Patients can be discharged home

5. What Is The Risk ICH For Patients on Antiplatelet Agents ?
Limited Evidence

6. Risk of ICH For Patients On Antiplatelet Agents

7. TICH and Antiplatelet Agents
Risk bleeding approximately 1.5
Warfarin approximately 2.5

8. TICH and Antiplatelet Agents
Cull et al. Am Surg. 2015
Cohort 1547 TBI
No significant increase TICH in patients on antiplatelet agents

9. What is the Risk of Intracranial Haematoma Expansion In Patients On Antiplatelet Agents ?

10. Meta-analysis For HP Only Studies available were Stroke patients.
No Studies published in patients with traumatic bleeds on antiplatelet agents which looked at the incidence of Haematoma Progression (HP).
Case Control or Cohort (nested case control group).
Patients also taking warfarin were excluded

11. Performed November 04/11/15 using PubMed
Search Strategy
Performed November 04/11/15 using PubMed
Stroke AND Haematoma Progression
Stroke AND Haematoma Expansion
Stroke AND Haematoma Growth
Abstracts = 55
Full Papers = 30
Accepted =5
Cross Referencing = 5 Additional Papers

12. Size Of Cohort Studies
Author APT HP NoHP NoAPT HP No HP Brouwers Okada Yang De Gea Garcia Yildiz Moussouttas Sansing Ishibashi Saloheimo Sorimachi Toyoda et al

13. Forest Plot: Results

14. What is the Impact on Mortality On patients with TBI And Antiplatelet Agents ?

15. Forest Plot For The 12 Studies In The Warfarin meta-analysis

16. Forest Plot For The Four Studies In The Aspirin meta-analysis

17. Forest Plot For The Four Studies In The Clopidogrel meta-analysis

18. TICH and Antiplatelet Agents
Should we be giving these patients platelet transfusions ?

19. Forest plot for the four traumatic intracranial haemorrhage studies.
Forest plot for the four traumatic intracranial haemorrhage studies. Fixed effects model.
Batchelor J S , Grayson A BMJ Open 2012;2:e000588
©2012 by British Medical Journal Publishing Group

20. Platelet Transfusion For TICH: Current Evidence
Bachelani et al. Surgery 2011.
N= patients pre-injury aspirin
Initial ART-VerifyNow: (aspirin response test)
54 patients showed evidence platelet dysfunction
including 54 (42%) not on aspirin.
Platelet transfusion reversed the platelet dysfunction in 29 patients (64.4%).

21. Platelet Transfusion For TICH: Current Evidence
Taylor et al. J Trauma
N=25. TICH All given Platelet transfusion
13- aspirin. 8-clopidogrel. 4-both
Using VerifyNow assay aspirin induced platelet dysfunction was reversed but not clopidogrel induced platelet dysfunction.

22. Taylor et al. J Trauma. 2013. 13 patients in the aspirin group
All 13 had ARU test < 550
After transfusion 12 ARU > 550
Aspirin Reaction Unit- amount of thromboxane A2 mediated activation
of GPIIb/IIa receptor involved in platelet aggregation. Range for aspirin inhibition No effect ARU > 550.

23. Taylor et al. J Trauma. 2013. 12 patients in the clopidogrel group
The inhibitory effect was reduced in all patients after transfusion by 20% but remained above the normal effect value 418 PRU.
Clopidogrel - Platelet Reaction Unit (PRU). Indicates the amount of ADP
mediated aggregation specific to the platelet P2y12 receptor . Normal range Above 418 indicates platelet inhibition.

24. Platelet Transfusion For TICH: Current Evidence
Joseph B et al. J Trauma adult patients with TICH All on high dose aspirin 325mg. VerifyNow assay.

25. Initial Cohort n=28 Patients TICH After Platelet Transfusion
Joseph B et al. J Trauma
Initial Cohort n=28 Patients TICH
22 NFP
6 FP
After Platelet Transfusion
78% no change in function
14% change from FP to NFP
7% changed from FP to NFP

26. Platelet Transfusion: Current Evidence
Briggs A et al J Surg Res 12 platelets on aspirin TICH Found that platelet transfusion improved aspirin (Arachidonic acid) assay but collagen induced platelet dysfunction. (Used Multiplate multiple electrode aggregometer)

27. Platelet Transfusion: Current Evidence
Kim DY et al J Neurotrauma TICH: 20% antiplatelet agents 126 patients given platelets + DDAVP 282 no treatment Haematoma progression: 43% P/D + and 34% P/D-ve

28. Desmopressin
Synthetic analogue of ADH. Release of Von Willebrands Factor. Is proven to improve platelet function.

29. Two Studies used Desmopresin
Naidech et al. Stroke 2014.
Stroke (ICH) patients n=14 patients.
Patient either antiplatelet agents or reduced platelet activity with point of care testing.

30. Naidech et al. Stroke 2014.
Improved platelet function in 13 out of 14 patients using Platelet Function Analyzer-epinephrine test after desmopressin.
Did not demonstrate a decrease in
haematoma expansion, which was the Primary End Point.

31. Kapapa T et al
Spontaneous or traumatic ICH. N=10 All patients received desmopressin Transient improvement in platelet function PFA-100 Analyser. Worsened after 3 hours. No complications with fluid overload in the elderly

32. Conclusions
Role of platelet transfusion is unclear in patients on anti-platelet agents and TICH. Desmopressin may prove to be a better alternative

33. Neurocritical Care Society (USA) Guidelines
Neurocritical Care Society (USA) Guidelines. Frontera et al, NeuroCrit Care. 2016
Recommendations
Platelet Transfusion should be considered for patients taking pre-injury aspirin and ADP receptor inhibitors if undergoing a neurosurgical procedure.
Consideration for the single dose of DDAVP (0.4mcg/kg iv) for aspirin and ADP receptor inhibitors
if undergoing a neurosurgical procedure.

34. Any Questions ?