Medical News Stories
Systematic Review and Meta-Analysis: Is Pre-Injury Antiplatelet Therapy Associated with Traumatic Intracranial Hemorrhage?
van de Brand CL, Tolido T, Rambach AH, et al. J Neurotrauma. 2017;34:1-7.
Study Question: Is there an increased risk of traumatic intracranial hemorrhage (tICH) on computed tomography (CT) brain scan with the use of antiplatelet therapy (APT) pre-injury?
Study Description: This systematic review included retrospective as well as prospective observational cohort studies and case-control studies that assessed the relationship between APT use and tICH risk from inception until September 2015. The primary endpoint was tICH on head CT. The quality of the studies was assessed by the Newcastle-Ottawa assessment scale (NOS) by two independent reviewers.
Results: Of the 3,165 studies identified, ten trials (20,247 participants) were included. Patients with pre-injury APT (aspirin, clopidogrel, ticlopidine, indobufen) were at an increased risk for tICH than those without pre-injury APT (OR 1.87, 95% CI 1.27-2.74). Strong evidence of heterogeneity (I2 84%) was seen among the included studies. Therefore, a sensitivity analysis was performed that excluded two studies with a high risk of bias and one study that had aspirin monotherapy. This sensitivity analysis showed that pre-injury APT was a risk factor for the development of tICH (OR 2.02, 95% CI 1.35-3.03, I2 85%). Sensitivity analysis that only included studies with mild traumatic brain injury (TBI) (GCS 13-15) resulted in pre-injury APT also being a risk factor for tICH (OR 2.72, 95% CI 1.92-3.85, I2 53%).
Conclusion: There is a clinically relevant association between pre-injury APT and tICH, which was increased the most in patients with mild TBI. Further prospective studies need to be conducted to confirm that APT use increases the risk of tICH.
Perspective: This review is limited due to the low strength of evidence and heterogeneity of the studies, including trial variability in the enrolled patient population, APT use, control group, and outcome definitions. The studies included different APT combinations
(clopidogrel + aspirin, clopidogrel + aspirin + ticlopidine, aspirin + ticlopidine + indobufen) or even APT monotherapy (clopidogrel or aspirin) which likely do not all have the same risk of tICH.