Consider<unk>  of aspirin and clopidogrel in acute life threatening hemorrhage, but it is very controversial in ICH
Risk of mortality from ICH on warfarin ~16-80%
Significantly higher mortality with either clopidogrel mono or dual-antiplatelet treatment in trauma patients
Aspirin alone is predictor of higher mortality in spontaneous ICH
PATCH trial in 2016 suggested mortality is higher in platelet transfused patients, alongside several other preceding studies
2.05 OR, increased odds of death at 3 months in platelet transfusion group
190 ICH patients enrolled
Included patients with at least 7 days of antiplatelet therapy, including ASA, clopidogrel, dipyridamole
Excluded SDH, epidural hemorrhage, aneurysm, AVM, surgical evacuation of ICH within 24 hrs, thrombocytopenia < 100k, use of warfarin if INR > 2-3, infratentorial hematomas, large intraventricular hemorrhage
Anti-platelet medications to reverse:
Aspirin
Clopidogrel
Ticagrelor
Ticlopidine (rarely used anymore)
Prevalence of immediate traumatic ICH in pts on clopidogrel 12% compared to 5% on warfarin
May be confounded by patients on warfarin having low threshold for presenting with head injury to ED, but highlights high frequency of bleeds in patients on clopidogrel
However, no patients on clopidogrel had delayed ICH compared to ~1% pts on warfarin with delayed ICH
Delayed ICH defined as traumatic ICH within 2 weeks after initial normal CTH
Platelet aggregation recovery:
Within 4 days of stopping aspirin
Takes 10 days for clopidogrel (life-span of a platelet)
When starting clopidogrel, takes 7 days to achieve max platelet inhibition
If 350mg loading dose, platelet inhibition occurs within 2-5 hrs
Risk of mortality from ICH on warfarin ~16-80%
Significantly higher mortality with either clopidogrel mono or dual-antiplatelet treatment in trauma patients
Aspirin alone is predictor of higher mortality in spontaneous ICH
2.05 OR, increased odds of death at 3 months in platelet transfusion group
190 ICH patients enrolled
Included patients with at least 7 days of antiplatelet therapy, including ASA, clopidogrel, dipyridamole
Excluded SDH, epidural hemorrhage, aneurysm, AVM, surgical evacuation of ICH within 24 hrs, thrombocytopenia < 100k, use of warfarin if INR > 2-3, infratentorial hematomas, large intraventricular hemorrhage
Included patients with at least 7 days of antiplatelet therapy, including ASA, clopidogrel, dipyridamole
Excluded SDH, epidural hemorrhage, aneurysm, AVM, surgical evacuation of ICH within 24 hrs, thrombocytopenia < 100k, use of warfarin if INR > 2-3, infratentorial hematomas, large intraventricular hemorrhage
Aspirin
Clopidogrel
Ticagrelor
Ticlopidine (rarely used anymore)
May be confounded by patients on warfarin having low threshold for presenting with head injury to ED, but highlights high frequency of bleeds in patients on clopidogrel
However, no patients on clopidogrel had delayed ICH compared to ~1% pts on warfarin with delayed ICH
Delayed ICH defined as traumatic ICH within 2 weeks after initial normal CTH
Within 4 days of stopping aspirin
Takes 10 days for clopidogrel (life-span of a platelet)
When starting clopidogrel, takes 7 days to achieve max platelet inhibition
If 350mg loading dose, platelet inhibition occurs within 2-5 hrs
When starting clopidogrel, takes 7 days to achieve max platelet inhibition
If 350mg loading dose, platelet inhibition occurs within 2-5 hrs
Anti-platelet agent reversal
Warfarin reversal
Dabigatran reversal
Rivaroxaban reversal
Unfractionated heparin reversal
Anticoagulants
Antiplatelet medications
Thrombolytics