Systematic Review of the Reversal of Antiplatelet and Anticoagulant Therapy in Traumatic Brain and Spinal Cord Injury

Introduction: Anticoagulant and antiplatelet therapy (AAT) is widely used for a variety of indications, especially in older populations. One adverse effect of AAT is an increased risk of bleeding with trauma, which can necessitate rapid reversal of their effects. In this study, we summarize the literature surrounding the reversal of AAT in traumatic CNS injury.

Methods: PRISMA guidelines were followed while conducting this systematic review. A search for clinical studies regarding AAT reversal on PubMed, EMBASE, Web of Science, Cochrane Trials, and the Health Research Premium Collection was performed. Qualitative and quantitative data were then extracted from studies meeting inclusion criteria for analysis.

Results: A total of 5147 papers were screened for inclusion following deduplication, with 25 studies included involving 4854 patients. Vitamin K antagonists (VKAs) were found to be readily reversible with fresh-frozen plasma (FFP), 4-factor prothrombin complex concentrate (4PCC), recombinant factor VIIa (rFVIIa), and vitamin K. 4PCC combined with vitamin K were found to be safest and most effective in normalizing INR, with rapid reversal resulting in similar outcomes to patients not on AAT. Reversal with FFP conferred less benefit, and reversal with rFVIIa conferred no benefit to patients. DOAC reversal was found to be beneficial by some smaller studies, however, larger and higher-quality studies found that it was not associated with improved outcomes. Reversal of antiplatelet agents with platelet transfusion was found not to be associated with any mortality benefit. However, one study concluded that administration of desmopressin decreased the rate of hematoma expansion in patients with mild traumatic brain injuries previously on antiplatelet therapy.

Conclusion : Reversal of anticoagulation with VKAs using 4PCC is safe and is associated with improved outcomes following CNS trauma. However, there is limited evidence supporting the benefits of reversal of DOAC anticoagulation, and reversal of antiplatelet agents with platelet transfusion is not associated with improved outcomes.