Antiplatelet reversal [Neurosurgery Wiki]

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====== Antiplatelet reversal ======
[[Antiplatelet therapy]] is common and complicates the operative [[management]] of acute [[intracranial hemorrhage]]. Little data exist to guide [[antiplatelet reversal]] strategies.

The use of [[antithrombotic]] agents, including [[anticoagulant]]s, [[antiplatelet]] agents, and [[thrombolytic]]s has increased and is expected to continue to rise. Although antithrombotic-associated [[intracranial hemorrhage]] can be devastating, rapid reversal of [[coagulopathy]] may help limit hematoma expansion and improve outcomes.

Data assessing the relationship between outcome and prehospital [[antiplatelet]] agents in the setting of [[ICH]] is conflicting in both the [[trauma]] and the [[stroke]] [[literature]]. Only one retrospective review specifically addressed outcomes after attempted reversal with [[platelet transfusion]]. Further study is needed to determine whether platelet transfusion ameliorates [[hematoma]] enlargement and/or improves outcome in the setting of acute ICH
((Campbell PG, Sen A, Yadla S, Jabbour P, Jallo J. Emergency reversal of
antiplatelet agents in patients presenting with an intracranial hemorrhage: a
clinical review. World Neurosurg. 2010 Aug-Sep;74(2-3):279-85. doi:
10.1016/j.wneu.2010.05.030. Review. PubMed PMID: 21492561.
)).

Raimondi et al., recommend discontinuation of the [[antiplatelet]], as well as administration of [[platelet transfusion]]s and [[desmopressin]] only in the setting of life-threatening [[bleeding]]
((Raimondi P, Hylek EM, Aronis KN. Reversal Agents for Oral Antiplatelet and
Anticoagulant Treatment During Bleeding Events: Current Strategies. Curr Pharm
Des. 2017;23(9):1406-1423. doi: 10.2174/1381612822666161205110843. Review. PubMed
PMID: 27917717.
)). 
----
An [[online survey]] detailing antiplatelet reversal strategies in patients presenting with acute operative intracranial hemorrhage ([[subdural hematoma]] (SDH), [[epidural hematoma]] (EDH), and [[intracerebral hemorrhage]] (ICH) was distributed to board certified [[neurosurgeon]]s in the [[North America]].

Of the 2,782 functional email addresses, there were 493 (17.7%) responses to question #1 and 429 (15.4%) completed surveys. Most respondents chose to perform no additional laboratory testing prior to surgical intervention, regardless of hemorrhage type. The most common antiplatelet reversal strategy in the presence of [[aspirin]] was [[platelet transfusion]] (SDH and ICH) or no intervention (EDH). The most common antiplatelet reversal strategy in the presence of an [[Adenosine diphosphate receptor inhibitor]] or [[DAPT]] was [[platelet transfusion]] or platelet transfusion with [[DDAVP]] administration. There was a statistically significant difference in management strategy depending on the antiplatelet therapy (p < 0.001).

When patients on antiplatelet medication present with operative intracranial hemorrhage, the majority of neurosurgeons do not perform qualitative [[platelet function testing]]. Antiplatelet reversal strategies are significantly influenced by the antiplatelet therapy with more aggressive reversal strategies employed in the presence of [[ADP]] [[antagonist]]s
((Foreman PM, Ilyas A, Mooney J, Schmalz PGR, Walters BC, Griessenauer CJ.
Antiplatelet Medication Reversal Strategies in Operative Intracranial Hemorrhage:
A Survey of Practicing Neurosurgeons. World Neurosurg. 2018 May 18. pii:
S1878-8750(18)31017-9. doi: 10.1016/j.wneu.2018.05.064. [Epub ahead of print]
PubMed PMID: 29783009.
)).

===== References =====