Platelets to prevent progression of trauma-induced head bleed in patients on antiplatelet medication

There are no established guidelines for transfusing platelets in the setting of traumatic brain injury (TBI)-related intracranial hemorrhage for patients on pre-injury antiplatelet medications (APT). Existing literature has produced mixed results regarding the effectiveness of platelet transfusion in containing bleed size or avoiding craniotomy. We compared outcomes of patients on APT with an intracranial bleed due to trauma, between those who did and who did not receive routine platelet transfusion.

This retrospective cohort study included patients on APT with TBI-associated intracranial hemorrhage treated at a level II trauma center between 1/1/2014 and 7/31/2018: before March 2017, patients received routine platelet transfusion during initial management ("old protocol"). From March 2017 patients received platelets only if needing craniotomy ("new protocol"). Primary outcome was need for operative management. APT type, intracranial bleed type, bleed size and shift on CT scans, demographic and clinical variables were obtained.

Patients were in their mid-70's and most had sustained a fall. Old protocol patients were more likely to be on clopidogrel (32.5% vs. 18.2% for new protocol, p = 0.016) and had larger bleeds on initial CT (10.1 vs. 6.9 for new protocol, p = 0.038). When stratifying by aspirin only and clopidogrel±aspirin, old protocol and new protocol patients did not differ on need for operative management (aspirin only p = 1.0; clopidogrel p = 0.55), change in bleed size (aspirin only p = 0.37, clopidogrel p = 0.068), or other outcomes.

We found no evidence that restricting platelet transfusion to patients needing operative management increased the risk of poor outcomes among patients on APT with TBI-associated intracranial hemorrhage.