Mr Batchelor. Consultant In Emergency Medicine

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Presentation transcript:

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

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

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.

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

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

Risk of ICH For Patients On Antiplatelet Agents

TICH and Antiplatelet Agents Risk bleeding approximately 1.5 Warfarin approximately 2.5

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

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

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

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

Size Of Cohort Studies Author APT HP NoHP NoAPT HP No HP Brouwers 354 68 286 290 32 258 Okada 81 11 70 397 60 337 Yang 68 16 52 265 59 206 De Gea Garcia 37 17 20 119 21 98 Yildiz 52 15 37 101 10 91 Moussouttas 17 5 12 53 15 38 Sansing 70 17 53 212 56 156 Ishibashi 17 1 16 221 35 186 Saloheimo 21 4 17 78 6 72 Sorimachi 19 5 14 164 1 163 Toyoda et al 57 9 48 194 12 182

Forest Plot: Results

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

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

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

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

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

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

Platelet Transfusion For TICH: Current Evidence Bachelani et al. Surgery 2011. N=84. 36 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%).

Platelet Transfusion For TICH: Current Evidence Taylor et al. J Trauma. 2013. 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.

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 350-550. No effect ARU > 550.

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 194-418. Above 418 indicates platelet inhibition.

Platelet Transfusion For TICH: Current Evidence Joseph B et al. J Trauma. 2013. 28 adult patients with TICH All on high dose aspirin 325mg. VerifyNow assay.

Initial Cohort n=28 Patients TICH After Platelet Transfusion Joseph B et al. J Trauma. 2013. 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

Platelet Transfusion: Current Evidence Briggs A et al. 2015. 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)

Platelet Transfusion: Current Evidence Kim DY et al J Neurotrauma 2015. 408 TICH: 20% antiplatelet agents 126 patients given platelets + DDAVP 282 no treatment Haematoma progression: 43% P/D + and 34% P/D-ve

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

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.

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.

Kapapa T et al. 2014 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

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

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.

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