What is the optimal management for bleeding in patients with traumatic brain injury and brain bleed, particularly regarding platelet count and coagulopathy?

From the Guidelines

The optimal management of bleeding in patients with traumatic brain injury (TBI) and brain bleed requires maintaining a platelet count above 100×10^9/L, as recommended by the most recent guidelines 1. This is crucial for preventing further bleeding and promoting hemostasis. The following key points should be considered:

• Platelet transfusions are prescribed to treat thrombocytopenia and prevent bleeding, with specific thresholds for different procedures, such as central venous catheter insertion, lumbar puncture, and major surgery 1.
• In patients with TBI, maintaining a platelet count above 100×10^9/L is essential, as recommended by the Association of Anaesthetists guidelines 1.
• Coagulopathy should be corrected by targeting an INR less than 1.4, and prothrombin complex concentrate (PCC) at 25-50 IU/kg is preferred over fresh frozen plasma for rapid reversal of anticoagulation, as suggested by previous studies 1.
• Tranexamic acid (TXA) 1 g IV over 10 minutes, followed by 1 g over 8 hours, can be administered within 3 hours of injury to reduce hemorrhage progression, although its benefit specifically in TBI remains debated 1.
• Fibrinogen levels should be maintained above 150-200 mg/dL using cryoprecipitate or fibrinogen concentrate, and hypotension should be avoided with a target systolic blood pressure above 110 mmHg to maintain cerebral perfusion pressure, as recommended by the European guideline on management of major bleeding and coagulopathy following trauma 1. Some key considerations for platelet transfusion thresholds include:
• Central venous catheter (CVC) insertion: 20 × 10^9/L
• Lumbar puncture: 40 × 10^9/L
• Insertion or removal of epidural catheter: 80 × 10^9/L
• Major surgery: 50 × 10^9/L
• Neurosurgery or posterior segment ophthalmic surgery: 100 × 10^9/L These thresholds are not based on high-quality data, and an ongoing trial is aiming to identify the optimal platelet transfusion threshold in critically ill patients requiring low-bleeding risk invasive procedures 1.

From the Research

Platelet Requirements for Traumatic Brain Injury and Brain Bleed

• The optimal management for bleeding in patients with traumatic brain injury and brain bleed involves transfusion of blood products, including platelets, packed red blood cells, and plasma 2.
• Platelet transfusion thresholds should be at least 50,000/mm(3) for patients without evidence of hemorrhage and 100,000/mm(3) for patients with evidence of hemorrhage 2.
• Reversal of antiplatelet therapy with platelet transfusion is advisable only in patients with active bleeding 2.
• Tests for platelet function are helpful in determining an adequate platelet transfusion in these situations 2.

Platelet Dysfunction in Traumatic Brain Injury

• Platelet dysfunction is a common phenomenon in traumatic brain injury and can contribute to bleeding complications 3.
• Patients with traumatic brain injury have lower platelet counts and longer bleeding times compared to healthy controls 3.
• Platelet responses to arachidonic acid are dramatically lower in patients with traumatic brain injury, which can be used to identify patients with a high risk of bleeding complications 3.

Effects of Platelet Transfusion on Outcome

• Platelet transfusion in patients with moderate thrombocytopenia was not significantly associated with outcome 4.
• Fresh frozen plasma transfusions alone or in combination with packed red blood cells were associated with poorer long-term functional outcomes in patients with moderate coagulopathy 4.
• Red blood cell transfusions were associated with poor long-term functional outcome in patients with moderate anemia 4.

Current Recommendations and Future Directions

• Platelet functional assays can be used to evaluate patients with traumatic brain injury and guide platelet transfusion therapy 5.
• Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome, but further studies are needed to confirm this 5.
• The use of platelet transfusions in patients on antiplatelet agents with intracranial hemorrhage may not have a clear beneficial effect on outcomes, but may slightly increase the odds for adverse events of thromboembolic origin 6.