Hatim Attar, MD
There are various strategies to tackle acute Intracerebral Hemorrhage (ICH) with intent to minimize the risk of hematoma expansion and preserve brain perfusion. These have been areas of interest for decades with ongoing research and regular updates in management. In today’s Neuro-Intensive care units, one increasingly encounters patients who are on various antiplatelet (AP) and anticoagulant (AC) agents. These agents, without a doubt, are implicated with spontaneous ICH and subsequent hematoma expansion, too. This review has addressed the burning question: Which hemostatic therapies should be used in spontaneous ICH in the setting of antithrombotic agents?
The authors searched multiple databases and reviewed all available international trials until November 2017. They included randomized controlled trials (RCTs) which evaluated any hemostatic intervention for acute spontaneous ICH. A total of 12 RCTs were found relevant and included in this review, which amounted to a total of 1732 participants. 7 RCTs, involving 1480 participants, were on administration of clotting factors, 3 RCTs with 57 participants on antifibrinolytic drugs, 1 RCT with 190 participants on platelet transfusion, and another 1 RCT with 5 participants on clotting factors vs. fresh frozen plasma. RCTs which used aggregated data for ICH, not differentiating spontaneous hemorrhages from others, were excluded.
The analysis showed only 1 RCT- the PATCH trial, for platelet transfusion vs. control in patients with anti-platelet related ICH. There was a significantly worse outcome in patients who received transfusions; risk ratio 1.29, C.I 1.04-1.61. As the majority of the RCTs were on clotting factors vs. control or placebo, encompassing over 85% of all their review participants, the authors have effectively tabulated these in their review. There was no statistically significant difference in the groups receiving clotting factors vs. placebo; risk ratio 0.87, C.I 0.70-1.07. Additionally, no significant difference in groups receiving antifibrinolytics vs. placebo in ICH risk ratio 1.25, C.I 0.57-2.75. Lastly, no significant difference in anticoagulation related ICHs between clotting factors or fresh frozen plasma (FFP), risk ratio 0.27, C.I 0.02- 3.74.
Putting these results together, the authors concluded that platelet transfusions were harmful in comparison to standard care in antiplatelet associated ICH. Further, no firm conclusions could be drawn on the efficacy and safety of clotting factors and antifibrinolytics in ICH or clotting factors vs. FFP in AC-related ICH.
This review really highlights that the evidence available is limited and the need for further investigation is tremendous. Pharmaceuticals are constantly rolling out newer and more potent antiplatelet agents. With their increased acceptance and use in the medical field, it is necessary to counter the potential complications. Likewise, there are novel anticoagulants available, too. The arsenal of hemostatic therapies has been increasing- Andexxa has been approved by FDA for reversal of factor Xa inhibitors. Naidech et al have published on the use of desmopressin in acute hemorrhage. Cryoprecipitate and FFP have their niche in AC-related hemorrhages. Ultimately, it becomes incumbent to correctly identify the etiology of the ICH. Accurately focusing on management options is then feasible.