Featuring a large virtual attendance, the May Neurocritical Care Society Twitter Journal Club featured a lively discussion on the article, “Management of Antithrombotic Drugs in Patients with Isolated Traumatic Brain Injury: An Intersociety Consensus Document” by Corraddo Iaccarino et al. The article was the culmination of a collaborative effort of a working group endorsed by the Neurotraumatology Section of the Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies. The working group developed 28 statements on the management of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in traumatic brain injury. The authors noted the low strength of evidence in previously published consensus documents due to their reliance on lower-quality studies.

A vibrant discussion was held on Twitter through #NCSTJC, and we will review the discussion topics and opinions expressed.

The discussion on bleeding risk assessment was kicked off by @tchaaban1 who noted: “Bleeding volume/thickness, coexisting coagulopathy, need for intervention, bleed stability are important factors.” He also linked to the criteria utilized by the working group authors. Other respondents generally agreed that bleed volume, hematoma expansion, and other underlying coagulopathy are important factors in guiding their risk assessment.

The second question asked participants to indicate their current DOAC reversal practice in otherwise low risk patients. @dcm7200 and @TJUHNeuroCrit both discussed utilizing TEG and ROTEM to assess bleeding risk to help guide both transfusion thresholds and DOAC reversal. @EderCaceres5 indicated: “Low bleeding risk: stop DOACs and clinical and imaging follow up. Bearing in mind when was the last dose of DOAC taken.” @Tchaaban1 had a pragmatic view of the authors approach stating that it “…totally makes sense in the absence of high-quality evidence. Cost and thrombosis risks are not to be underestimated.”

Question three featured a poll regarding the uncertainty of utilizing platelet transfusions in patients at high risk for bleeding who were on antiplatelet agents. The poll asked participants about their current practice, with the majority choosing to transfuse only in situations where a procedure was required. Some utilized DDAVP to potentially reverse the antiplatelet effects, with fewer respondents choosing to transfuse if a coagulopathy exists.

The discussion on question four was initiated by @tchaaban1 stating: “Our cut off is 1.5 in patients who have traumatic intracranial hemorrhage. We delay/avoid reversal if minimal bleed with very high thrombosis risk ie mechanical MVR and recent (<1month) VTE.”@Apaulsonrngmai1 indicated: “We tend to treat around 1.5 to 1.7 but do a lot of wait and see – follow up CT and good neuro exams make a difference”. Most agreed that mechanical valves complicate the decision and many defer vitamin K in this specific population. @TheABofPharmaC indicated: “…We do the combination of both PCC and Vitamin K in most cases of acute TBI on VKA therapy.” @NezerSara raised the important point that more patients are on DOAC these days, so the INR target is often no longer relevant.

The working group did not specifically address the safety or timing of resuming antithrombotic therapy on isolated traumatic brain injury patients. @KeatonSmetana noted: “Indication and severity of injury are critical determinants for resuming antithrombotic therapy in TBI patients.” Many, including @paulsonrngmai1, @TJUHNeuroCrit, and @EderCaceres5 noted patient-specific factors and provider opinions are important indicators in the ultimate decision. Multiple participants also noted the importance in understanding the underlying reason for antithrombotic therapy, both in determining the need for early reinitiation and in considering whether the medication is still indicated.

Question 6 featured another poll with potentially interesting results especially given ongoing clinical trials featuring the use of andexanet alfa. When considering reversal agents for DOACs in patients with high bleeding risk, a vast majority of respondents voted for PCC as their agent of choice. Some indicated a preference for using both, while others solely utilized andexanet alfa. @gdomeni raised an important point regarding the availability of andexanet alfa: “In low and middle-income countries is very difficult the access to andexanet”. Many hospitals in the United States also do not have the medication on their formulary, which may have influenced the overall preference toward PCC as well.

As a final summary discussion, the last question asked participants to consider the literature gaps which warrant further research to help bring clarity to the topic. @NezerSara indicated “…using TEG and other assays of functional clotting are the next step to balance understanding of clotting vs bleeding risk”. Her response referenced an additional discussion between @GilbertPharmD, @KeatonSmetana, and @tchaaban1 on the utilization of lab measures such as PT/INR, anti-Xa, and functional assays like TEG/ROTEM to assess the need for reversal. Variability across labs, institutions, and time to results were all indicated as factors in the decision to utilize lab or functional assays to guide reversal.

The May edition of the #NCSTJC featured a vibrant discussion regarding the management of antithrombotic agents in traumatic brain injury. The online discussion indicated both consensus on components, such as the reversal of DOAC with PCC, and only utilizing platelets in the setting of procedures. An area identified for potential exciting advancements was the utilization of functional clotting assays such as TEG and ROTEM to guide reversal and risk of antithrombotic agents.