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Three Part Question

In [patients on antiplatelet therapy suffering froma traumatic intracranial hemorrhage],does [platelet transfusion] improve [survival]?

Clinical Scenario

An unconscious 67-year-old male involved in a motor vehicle accident is brought to the emergency departmentby paramedics. The head CT shows a frontal contusion. The patient is on Clopidogrel. You wonder if the antiplatelet therapy reversal with platelet transfusion would improve patient’s survival.

Search Strategy

A. No BestBETs or critical appraisals were found on this topic.
B. There was no Cochrane review found on the subject.
C. www.clinicaltrials.gov was searched for an ongoing trial on the topic andnone was found.
D. Medline 1900 to December 15 2012 via Pub med :

1. \\\"Intracranial Hemorrhages\\\"[Mesh] : 51770
2. \\\"Platelet Aggregation Inhibitors\\\"[Mesh] : 24039
3. \\\"Platelet Transfusion\\\"[Mesh] : 4275
4. \\\"Wounds and Injuries\\\"[Mesh] : 652 943
5. 1 AND 2 AND 3 AND 4 :7

1 relevant article

E. Embase>1946 to December 15 2012 :

1. Thrombocyte Transfusion : 9 906
2. Brain Hemorrhage : 77 790
3. Antithrombocyticagent : 244 010
4. Injury : 1 591 609
5. 1 AND 2 AND 3 :61

2 relevant articles(1 new article)

Search Outcome

F. SEARCH OUTCOME: 2 studies were found to be relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Batchelor J. and Grayson A. 2012 United Kingdom	Meta-analysis of 6 retrospectivestudies (2 on spontaneous and 4 on traumatic intracranial hemorrhage). A total of 716 patients with traumatic intracranial hemorrhage on antiplatelet therapy. 316 of those patients received platelet transfusion	Meta-analysis	Survival for traumatic intracranial hemorrhage	OR = 0,609 (p= 0,018)	A meta-analysis of retrospective studies Survival and selection bias in the studies Significant heterogeneity between the studies (I2=58,276) Platelet transfusions at the discretion of the physician in most studies (indication and quantity)
Nishijima D and al. 2012 USA	Inclusion of 5 retrospective studies (2 studies different from the meta-analysis). A total of 746 patients with traumatic intracranial hemorrhage on antiplatelet therapy. 366 of those patients received platelet transfusion	Systematic review	Mortality rate for traumatic intracranial hemorrhage	3 studies showed no statistical differences between the platelet transfusion group and the control group	Retrospective studies only Survival and selection bias in the studies Platelet transfusions at the discretion of the physician in most studies (indication and quantity) For the positive study, only 19 patients in the control group Inclusion of concomitant warfarin use in most studies
				1 study (90 patients) with RR =2,42 (1,18-4,96) NNH = 4
				1 study (111 patients) with RR =0,21 (0,05-0,95) NNT = 7

Comment(s)

We found a systematic review and a meta-analysis(including a total of 6 different retrospective studies) which both conclude that there was no evidence to support the use of platelet transfusion in patients with antiplatelet use and traumatic intracranial hemorrhage. Only one study showed a significant decrease in mortality but itincluded several methodological weaknesses and had a large confidence interval. The meta-analysis showed a significant lower survival rate in the platelet transfusion group. However, the 4 retrospective studies have significant heterogeneity and suboptimal methodologies

Clinical Bottom Line

In patients on antiplatelet therapy suffering from a traumatic intracranial hemorrhage, there are currently no sufficient data to support the use of platelet transfusion to improve patient outcome.

References

1. Batchelor JS, Grayson A. A meta-analysis to determine the effect on survival of platelet transfusions in patients with either spontaneous or traumatic antiplatelet medication-associated intracranial haemorrhage BMJ Open 2012;2(2):e000588.
2. Nishijima DK, Zehtabchi S, Berrong J, Legome E. Utility of platelet transfusion in adult patients with traumatic intracranial hemorrhage and preinjury antiplatelet use: a systematic review. J Trauma Acute Care Surg 2012;72(6):1658-63.