The Case

A 67-year-old woman presents with sudden onset of right-sided hemiparesis and facial droop. She takes aspirin daily. The noncontrast head CT shows a hemorrhagic stroke. Would a platelet transfusion be of benefit?

Background

Antiplatelet therapy prior to a hemorrhagic stroke raises the risk of death by 27 percent, and more than 25 percent of patients with intracerebral hemorrhages (ICHs) were taking antiplatelet therapy.¹

Reversal of antiplatelet medications in patients with ICH was addressed in a publication by Martin and Conlon.² They stated, “None of these studies showed a mortality benefit or improved functional outcome with platelet transfusion in patients with spontaneous or traumatic intracerebral hemorrhage who were receiving antiplatelet medications.”

They also said there are “no compelling data currently supporting the use of platelet transfusion” and that “it would be within the standard of care to withhold platelet transfusion in patients with either spontaneous or traumatic intracerebral hemorrhage who are receiving antiplatelet therapy.” The review did note that the existing evidence at the time was all based on relatively small retrospective studies.

The recommendation from the neurosurgical perspective states, “At present, the literature contains insufficient information to establish any guidelines or treatment recommendations. Considering this, the current authors have proposed a protocol for antiplatelet reversal in both spontaneous and traumatic acute ICH.”³

Clinical Question

In patients with acute nontraumatic hemorrhagic stroke, does platelet transfusion reduce death or disability?

Reference

Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605-2613.

• Population: Adults 18 years or older with nontraumatic ICH with a Glasgow Coma Scale rating of greater than 7 in whom platelets could be transfused within six hours of symptom onset and who used antiplatelet therapy for at least seven days.
• Exclusions: Epidural or subdural hematoma, underlying aneurysm or arteriovenous malformation, planned surgery within 24 hours, intraventricular blood more than sedimentation in the posterior horns, previous adverse reaction to platelet transfusion, known use of vitamin K antagonists or history of coagulopathy, known thrombocytopenia, lacking mental capacity, or death appeared imminent.
• Intervention: Platelet transfusions within six hours of supratentorial ICH symptom onset and within 90 minutes of diagnostic brain imaging.
• Comparison: Standard care.
• Outcomes:
  • Primary: A shift toward death or dependence scored with the modified Rankin Scale (mRS) at three months.
  • Secondary: Survival, poor outcome (mRS 4–6), poor outcome (mRS 3–6), hemorrhage growth after 24 hours, transfusion issues (reactions and thrombotic complications), and other serious adverse events.