What is the role of platelet transfusion in managing intracranial hemorrhage (ICH) in patients on antiplatelet therapy, based on the PATCH (Platelet Transfusion in Cerebral Hemorrhage) trial?

Platelet Transfusion in Intracranial Hemorrhage for Patients on Antiplatelet Therapy

Platelet transfusion should NOT be administered to patients with spontaneous intracranial hemorrhage who are on antiplatelet therapy, as it may worsen outcomes rather than improve them. 1, 2

Evidence from the PATCH Trial

The PATCH (Platelet Transfusion in Cerebral Hemorrhage) trial was a landmark randomized controlled trial that specifically addressed this clinical question:

• Included 190 non-thrombocytopenic patients with intracranial hemorrhage (ICH) who were taking antiplatelet medications
• Patients had Glasgow Coma Scale (GCS) scores > 8 and did not require emergency neurosurgery
• Found that platelet transfusion was associated with worse outcomes compared to standard care:
  • Higher odds of death or dependence at 3 months (adjusted common odds ratio 2.05,95% CI 1.18-3.56) 2
  • More serious adverse events during hospital stay (42% vs 29%) 2

Current Guideline Recommendations

Based on the PATCH trial and other evidence, current guidelines recommend:

1. For non-surgical ICH patients on antiplatelet therapy:

   • Restrictive platelet transfusion strategy (no transfusion) is recommended 1
   • Platelet transfusion may actually increase mortality and dependence 1

2. For ICH patients requiring neurosurgical intervention:

   • Platelet transfusion may be considered before surgery 1
   • Platelet function testing is recommended prior to transfusion when possible 1
   • No transfusion if platelet function is documented to be within normal limits 1

Management Algorithm for ICH Patients on Antiplatelet Therapy

1. First step: Discontinue antiplatelet agents immediately when ICH is present or suspected 1

2. For patients NOT requiring neurosurgical intervention:

   • Avoid platelet transfusion regardless of:
     • Type of platelet inhibitor
     • Platelet function testing results
     • Hemorrhage volume
     • Neurologic examination 1

3. For patients requiring neurosurgical intervention:

   • Consider platelet transfusion for aspirin or ADP inhibitor-associated ICH 1
   • Perform platelet function testing prior to transfusion if possible 1
   • Initial dose: one single donor apheresis unit of platelets 1
   • Consider desmopressin (0.4 μg/kg IV) as an adjunct therapy 1
   • Avoid platelet transfusion if platelet function tests are normal 1

Special Considerations

• Type of antiplatelet agent matters:

  • For NSAID or glycoprotein IIb/IIIa inhibitor-related ICH, platelet transfusion is not recommended even before neurosurgery 1
  • For ticagrelor, platelet transfusion may be ineffective; consider rFVIIa if last intake was within 24 hours 1

• Timing considerations:

  • Platelet transfusion may be less effective if administered <6 hours after the last intake of clopidogrel or prasugrel 1
  • For patients requiring platelet transfusion, earlier administration (within 12 hours of symptom onset) may be more beneficial than later administration 1

Potential Harms of Platelet Transfusion

• Increased mortality and dependence 2
• Higher risk of recourse to surgery 1
• Increased ICU length of stay 3
• Serious adverse events during hospitalization 2

The evidence clearly demonstrates that routine platelet transfusion for ICH patients on antiplatelet therapy who do not require neurosurgical intervention is harmful rather than beneficial. The PATCH trial provides the strongest evidence against this practice, showing worse outcomes with platelet transfusion compared to standard care alone.