What is the indication for reversal of anticoagulation or antiseizure medications in a patient with a subdural hematoma on Aspirin (Asa) and Brilinta (Ticagrelor)?

From the Guidelines

Reversal of anticoagulation is indicated for patients with subdural hematoma on Aspirin and Ticagrelor to reduce the risk of hematoma expansion and improve outcomes. For patients on these antiplatelet agents with subdural hematoma, immediate platelet transfusion (typically 1-2 units) is recommended, especially if neurosurgical intervention is planned, as suggested by 1. Additionally, desmopressin (DDAVP) at 0.3 mcg/kg IV can be administered to enhance platelet function. However, for Ticagrelor specifically, platelet transfusion may not be effective due to its long half-life and the presence of its active metabolite in plasma, which can inhibit transfused platelets, as noted in 1.

Key Considerations

• Platelet function testing, if available, can guide further management, as recommended by 1.
• Antiseizure medications are not typically reversed but may be initiated prophylactically with levetiracetam 500-1000mg twice daily for 7 days if seizure risk is elevated due to the hematoma's size or location.
• The goal is to restore normal hemostasis as quickly as possible to limit hematoma expansion and facilitate surgical intervention if needed, considering the guidelines from 1 and 1.

Management Approach

• Discontinue antiplatelet agents when intracranial hemorrhage is present or suspected, as advised by 1.
• Consider the use of desmopressin in appropriate cases, such as those undergoing neurosurgical procedures, as suggested by 1.
• Be cautious with the use of platelet transfusion in patients on Ticagrelor due to potential ineffectiveness, as discussed in 1.

Outcome Prioritization

The management strategy prioritizes reducing morbidity and mortality by minimizing the risk of hematoma expansion and improving neurological outcomes, aligning with the principles outlined in 1 and 1. Quality of life is also considered by aiming to restore normal hemostasis and facilitate surgical intervention if necessary, thus potentially reducing long-term neurological deficits.

From the Research

Indication for Reversal of Anticoagulation

• The indication for reversal of anticoagulation in a patient with a subdural hematoma on Aspirin (Asa) and Brilinta (Ticagrelor) is based on the risk of major bleeding episodes, including intracranial hemorrhage (ICH) 2.
• Early recognition, discontinuation of the medication, and appropriate management are crucial for a good clinical outcome 2.
• The use of protamin sulfate or human plasma fraction PPSB can provide normal coagulability in a few minutes 3.
• Immediate correction of hypocoagulability by administration of vitamin K and fresh frozen plasma and normalization of PA by calcium heparin is recommended 4.

Indication for Antiseizure Medications

• The indication for antiseizure medications in a patient with a subdural hematoma is based on the risk of clinical and/or electrographic seizures 5.
• Levetiracetam and phenytoin are commonly used for seizure prophylaxis in subdural hematomas, with levetiracetam associated with a lower risk of adverse drug effects 5.
• The choice of antiseizure medication should be based on the individual patient's risk factors and medical history.

Reversal Strategies and Surgical Management

• Careful hematologic management is required in surgical patients with traumatic acute subdural hematoma (aSDH) taking antithrombotic medications 6.
• Patients taking antiplatelets who received platelet transfusion had longer intraoperative times and higher rates of palliative care consultations compared with patients taking anticoagulants who received pharmacologic reversal and patients not taking antithrombotics 6.
• The use of pharmacologic reversal agents or platelet transfusions should be based on the individual patient's risk factors and medical history.