Desmopressin for antiplatelet-associated traumatic intracranial hemorrhage: A systematic review

Pre-injury antiplatelet therapy is common in traumatic brain injury (TBI) and may worsen outcomes after traumatic intracranial hemorrhage (tICH). Desmopressin (DDAVP) is used off-label to enhance platelet function, but evidence is mixed. To evaluate clinical outcomes after DDAVP for antiplatelet reversal in adults with tICH. We searched PubMed/MEDLINE, Embase, and Scopus (2000-2025). Eligible studies enrolled adults with TBI and acute tICH on aspirin and/or a P2Y12 inhibitor who received DDAVP and reported clinical outcomes. Of 57 records screened, 13 full texts were assessed, and 3 retrospective cohorts met our inclusion criteria. Heterogeneity in design, dosing/timing, and outcome definitions precluded from performing a meta-analysis.Three cohorts comprising a total of 5841 patients were included: a large multicenter registry comparing DDAVP, platelets, both, or no reversal; a two-center cohort comparing DDAVP+platelets vs no reversal; and a single-center mild-TBI cohort comparing DDAVP vs no DDAVP. In mild TBI, DDAVP was associated with lower hematoma expansion (adjusted OR ≈0.26). Across multicenter analyses, DDAVP conferred no mortality benefit; platelet transfusion ± DDAVP was associated with longer ICU/hospital length of stay and more complications than no reversal. Thrombotic events were infrequent and not clearly increased with DDAVP. Evidence for DDAVP in antiplatelet-associated tICH is limited and heterogeneous. A radiographic benefit with reduced hematoma expansion was seen in mild TBI, but consistent improvements in survival or functional outcomes were not found. Reviewed studies showed no clear advantage in platelets transfusion. Our review mostly found that TBI-specific randomized trials with standardized hematoma expansion definitions, prespecified repeat-CT windows, and safety monitoring are needed to definitively clarify the role of DDAVP in antiplatelet-associated tICH and to guide evidence-based clinical practice.