When to Stop Antiplatelets Before Lumbar Puncture
Aspirin does not need to be discontinued before lumbar puncture and can be safely continued, while P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) should be stopped 5-7 days before the procedure. 1
Aspirin Management
- Aspirin can be safely continued without any delay before lumbar puncture. 1
- The UK Joint Specialist Societies guideline explicitly states that aspirin and other non-steroidal anti-inflammatory medications do not require discontinuation prior to LP. 1
- This recommendation is supported by large observational data showing no increased risk of spinal hematoma in patients undergoing neuraxial procedures on aspirin. 2
- Aspirin is not a contraindication to lumbar puncture if there is no associated abnormality of hemostasis, including concurrent anticoagulant therapy. 2
P2Y12 Inhibitor Management
For clopidogrel:
- Discontinue 5-7 days before lumbar puncture. 2, 1
- If LP cannot be delayed, consider platelet transfusion or desmopressin (DDAVP) after discussion with hematology. 1
For prasugrel:
- Discontinue 7 days before the procedure. 2
For ticagrelor:
- Discontinue 5 days before the procedure. 2
Dual Antiplatelet Therapy Considerations
- While traditional guidelines recommend stopping P2Y12 inhibitors, emerging evidence suggests LP may be safer than previously thought even on dual antiplatelet therapy. 3, 4
- A retrospective study of 159 patients who underwent LP on ADP receptor antagonists (51% on dual therapy with aspirin) showed no spinal hematomas or neurological deficits, with traumatic tap rates of only 5%. 3
- Another study of 100 patients on dual antiplatelet therapy showed no serious complications, with traumatic LP rates (8%) within normal ranges. 4
Platelet Count Requirements
- The standard recommendation is to maintain platelet count ≥50 × 10⁹/L for elective diagnostic lumbar puncture. 2
- For patients with thrombocytopenia, LP should not be performed at platelet counts <40 × 10⁹/L or with rapidly falling platelet counts. 1
- Recent evidence suggests that in oncology patients, LP can be performed safely even at lower platelet counts without increased hemorrhagic complications. 5, 6
Clinical Decision-Making Algorithm
For urgent/emergent LP (suspected meningitis/encephalitis):
- Proceed immediately on aspirin without delay. 1
- For patients on P2Y12 inhibitors, the benefits of immediate diagnosis typically outweigh bleeding risks in life-threatening situations. 1
- Review the situation every 12-24 hours if LP must be delayed. 1
For elective LP:
- Continue aspirin throughout. 1
- Stop clopidogrel 5-7 days before, prasugrel 7 days before, ticagrelor 5 days before. 2, 1
- Ensure platelet count ≥50 × 10⁹/L (or ≥40 × 10⁹/L based on institutional protocols). 2, 1
Important Caveats
- These recommendations assume no other coagulopathy or concurrent anticoagulation. 2, 1
- For patients on warfarin, ensure INR ≤1.4 before LP. 1
- For patients on therapeutic LMWH, wait 24 hours after last dose; for prophylactic LMWH, wait 12 hours. 1
- For novel oral anticoagulants (apixaban, dabigatran, rivaroxaban), seek expert hematology consultation. 1
- Use atraumatic needles when possible to reduce post-LP complications. 2