Reversing Coagulopathy in Traumatic Brain Injury: PATCH Trial

Ronan O’Leary discusses reversing coagulopathy in traumatic brain injury. The PATCH trial was a trial look at the use of platelets to reverse the effects of aspirin and clopidogrel in patients with spontaneous cerebral haemorrhage. Ronan asserts that overall platelets are harming patients. Through his talk he highlights many studies that have been inconclusive about the benefits of giving platelets in traumatic intracerebral haemorrhage. As one study eloquently described, “It was not possible to determine if platelet transfusion was superior, inferior or not different from control interventions.” So why are platelets given at all? In haemorrhage, reduced platelet activity is associated with adverse outcomes. This is demonstrated with larger haematoma size in patients with lower platelet counts. So, it would make sense that replacing platelets should lead to better outcomes. However, this is not the case. Furthermore, as Ronan articulates, sometimes it just feels better to do something over nothing. The aetiology of the condition probably has nothing to do with platelets in the first place. Instead, non-traumatic intracerebral haemorrhages are likely caused by atherosclerotic disease, with changes in microvascular anatomy and brittle vessels leading to haemorrhage. Further, transfusing a patient with intracerebral haemorrhage with platelets may lead to secondary ischaemic change. Platelets have many proinflammatory and prothrombotic properties. So are the harms of platelets outweighed by the benefits… probably not. Ronan will go on to discuss the potential to extrapolate this evidence to traumatic brain injury patients. He concludes, probably not, mainly due to the mechanism of haemorrhage being the transmission of kinetic energy which is at odds with that of spontaneous intracerebral haemorrhage.

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