Emergency Reversal of Antiplatelet Agents in Patients Presenting with an Intracranial Hemorrhage: A Clinical Review

OBJECTIVE: Prehospital use of antiplatelet agents has been associated with an increased risk for intracranial hemorrhage (ICH) as well as a secondary increase in ICH volume after the initial hemorrhage. Strategies to reestablish platelet aggregation are used in clinical practice, but without any established guidelines or recommendations. This article serves to evaluate the literature regarding "reversal" of antiplatelet agents in neurosurgical populations. METHODS: PubMed and MEDLINE databases were searched for publications from 1966 to 2009 relating to intracranial hemorrhage and antiplatelet agents. The reference sections of recent articles, guidelines, and reviews were reviewed and pertinent articles identified. Studies were classified by two broad subsets: those describing intracranial hemorrhage relatable to a traumatic mechanism and those with a spontaneous intracranial hemorrhage. Two independent auditors recorded and analyzed study design and the reported outcome measures. RESULTS: For the spontaneous intracranial hemorrhage group, nine reports assessing antiplatelet effects on various outcome measures were identified. Eleven studies evaluating the use of prehospital antiplatelets before a traumatic intracranial hemorrhage were examined. CONCLUSION: The 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.