Key result
NOACs reduce ICH versus warfarin while new antiplatelets pose similar or higher risk than clopidogrel.
Why the study?
New oral anticoagulant and antiplatelet agents have emerged with potential for better outcomes but carry risks of intracranial hemorrhage requiring neurosurgical awareness of their management.
New oral anticoagulants have a lower incidence of intra-cranial hemorrhage compared to warfarin, while new antiplatelet agents have similar or increased risks compared to clopidogrel, necessitating specific monitoring and reversal strategies in neurosurgical emergencies.
May guide anticoagulant choice to minimize ICH risk; leaves open neurosurgery-specific validation.
Until recently, warfarin, clopidogrel and aspirin have provided the mainstay for prevention of thrombotic disease in cardiac patients. However, new classes of drugs have recently emerged that promise better clinical outcomes and lower risks. Use of such agents has increased, but increased risk and severity of intra-cranial haemorrhage (ICH) still remain. These cases of intra-cranial bleeds present as emergencies to neurosurgical units. It is of paramount importance that neurosurgical practitioners are aware of those new drugs, useful monitoring tests and available emergency reversal options in case the patient needs emergency intervention. In this review we survey newly available agents in the U.K. at the time of publication. We look at the data provided by the manufacturers, related publications and international guidelines for their use and reversal. New anticoagulants offer a lower incidence of ICH compared with warfarin. Advanced and accurate monitoring tests are emerging, as are prospective data on reversal of anticoagulation in bleeding. Some standard coagulation tests may be of use, whilst reversal agents are available and being evaluated. The trial data shows that new antiplatelet agents have similar or increased incidence and severity of intra-cranial ICH compared with clopidogrel. There is currently limited data on monitoring or reversal. We suggest they may be managed similarly to clopidogrel by using platelet reactivity assays, optimising platelet count and using platelet transfusion with adjunctive agents.
No takes yet. Share an insight, caveat, or question.
Kimpton et al. (2015) conducted a review in Thrombotic disease and intra-cranial haemorrhage. New oral anticoagulant and antiplatelet agents vs. Warfarin, clopidogrel, and aspirin was evaluated on Incidence and severity of intra-cranial haemorrhage (ICH). New oral anticoagulants offer a lower incidence of intra-cranial haemorrhage compared with warfarin, while new antiplatelet agents have similar or increased incidence compared with clopidogrel.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: