Emergency reversal of anticoagulation and antiplatelet therapies in neurosurgical patients

Abstract

Intracranial hemorrhage (ICH) is a common problem encountered by neurosurgeons. Patient outcomes are influenced by hematoma size, growth, location, and the timing of evacuation, when indicated. Patients may have abnormal coagulation due to pharmacological anticoagulation or coagulopathy due to underlying systemic disease or blood transfusions. Strategies to reestablish the integrity of the clotting cascade and platelet function assume a familiarity with these processes. As patients are increasingly treated with anticoagulants and antiplatelet agents, it is essential that the physicians who care for patients with ICH understand these pathways and recognize how they can be manipulated to restore hemostasis.

Hematologic Issues in the Geriatric Surgical Patient

“…There is no FDA-approved antidote, but some intracranial hemorrhage data advocate platelet transfusion to reverse the effects of aspirin by providing platelets with COX-1 activity. 15,20 …”

“…Because preinjury clopidogrel use is associated with significantly higher mortality in elderly patients with trauma, transfusion of platelets is advocated. 15,21 …”

“…14 Transfusion of fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) is used for rapid reversal of warfarin. 15 PCC has several advantages over FFP: it is virally inactivated, it does not require thawing or blood typing, and it can achieve therapeutic levels with a smaller volume of infused medication. 16 Recently, the 4-factor PCC (Kcentra) has been approved by the US Food and Drug Administration (FDA) for urgent reversal of warfarin.…”

The role of anticoagulants, antiplatelet agents, and their reversal strategies in the management of intracerebral hemorrhage

“…3,40 A platelet transfusion of 10-12.5 units of platelets has been shown to restore normal platelet function in patients on aspirin and clopidogrel. 74 Desmopressin has been known to increase platelet reactivity in patients treated with aspirin by releasing a greater number of von Willibrand multimers.…”

The Emergent Reversal of Coagulopathies Encountered in Neurosurgery and Neurology: A Technical Note

“…19 This is certainly the case for non-steroidal anti-inflammatory drugs, aspirin, and clopidogrel, prasugal, abciximab, cilostazol, and aggrenox. Admittedly, this is an area of active investigation for two reasons: (1) lab work to measure the extent of antiplatelet activity is notoriously inaccurate, and (2) the need for reversal for minor cases has not been validated (nor has the efficacy).…”