Lumbar puncture and antithrombotic therapy

David Goldemund M.D.
Updated on 08/12/2023, published on 07/02/2022

  • lumbar puncture (LP), also known as a spinal tap, is an important and commonly performed invasive procedure for obtaining cerebrospinal fluid (CSF) for diagnostic purposes
  • the procedure carries some risk of spinal bleeding (most often in the form of an epidural hematoma)
  • high-risk conditions include:
    • coagulopathies (including pharmacologically induced)
    • advanced age
    • multiple puncture attempts
    • existing spinal pathology
  • the potential benefit of the procedure must outweigh the risk of bleeding
  • avoid repeated puncture attempts in high-risk patients
  • spinal hematoma should be suspected if sudden sensorimotor and/or sphincter deficits or severe low back pain occur after puncture ⇒ perform MRI immediately and consult a neurosurgeon ( after > 8h, the prognosis is already unfavorable despite successful surgery!) [Herlocker, 2010]
  • on the other hand, periprocedural discontinuation of antithrombotic medication increases thromboembolism risk
    • aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes (Burger, 2005)
  • the potential benefit of lumbar puncture must always outweigh the risk of thrombosis
  • bridging therapy may be necessary in high-risk patients
  • consultation with the specialist who prescribed the antithrombotic therapy and a hematologist is recommended


Routine coagulation and CBC
  • routine CBC + coagulation tests should be performed prior to lumbar puncture; however, this is not explicitly mentioned in the recommendations for patients without a history of bleeding or hepatopathy
  • always perform in patients:
    • with known coagulopathy or a history of bleeding
    • on anticoagulant therapy
    • with hepatopathy or nephropathy
  • consult a hematologist if pathological results are obtained
  • the procedure is considered safe if the following platelet count thresholds are met:
    • lumbar puncture: platelet count > 40×109/L
    • epidural/spinal anesthesia:  platelet count > 80×109/L  [Van Veen, 2009]
  • assess the risk-benefit ratio individually, and consider concomitant risk factors (such as the use of antiplatelet drugs, etc.) in cases where the platelet count falls within these ranges:
    • lumbar punction: platelet count 20-40×109/L
    • epidural/spinal anesthesia: platelet count 40-80×109/L
  • consider a preprocedural consultation with a hematologist and the administration of platelet concentrate
Inherited coagulopathies
  • always manage these patients in collaboration with a hematologist
  • caution is necessary in patients with a positive family history who have not yet been diagnosed

Antiplatelet therapy

  • low-dose ASA (100 mg) does not increase the risk of bleeding in minor procedures (incl. lumbar puncture)
  • it has also not been found to increase the risk of bleeding during epidural anesthesia (when ASA was given for pre-eclampsia) ⇒ no need to discontinue low-dose ASA
  • only high doses (> 300 mg daily) probably increase the risk of bleeding
P2Y12 inhibitor monotherapy
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Dual antiplatelet therapy (DAPT)
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GP IIb/IIIa antagonists
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  • discontinue cilostazol 42 hours before the procedure and restart after 5 hours    [Gogarten, 2010]
  • dipyridamole has a half-life of 10-12 hours; no special precautions are needed, and it can be resumed after 6 hours

Urgent reversal of antiplatelet drugs effect

  • prophylactic reversal of antiplatelet therapy is not a routine procedure and should generally be avoided due to the risk of thrombosis
  • 2-3 units of platelets may be considered to provide functional, circulating platelets; consult a hematologist
    • studies have shown mixed results regarding the benefit of this practice; there is no standard dose, and no effect was shown in the PATCH trial
  • desmopressin (ddAVP) OCTOSTIM – 0,3 ug/kg +100 mL of NS, infused over 15-30 minutes
    • the benefit of using desmopressin before lumbar puncture remains unproven; data are only available for general surgery (where a reduced need for transfusion was reported) (Desborough, 2016)
  • it is safe to perform a lumbar puncture if INR is ≤ 1.4
  • discontinue warfarin 4-5 days before the procedure; the drop in INR varies individually and is difficult to predict
    • the rapid decrease in INR in the first 3 days after warfarin discontinuation reflects an increase in factor VII activity. However, hemostasis may remain compromised due to deficiencies in factors II and X (which take longer to normalize) [Herlocker, 2010]
    • if early lumbar puncture is required, administer KANAVIT 5 mg IV  > 6-8 h before the procedure and then recheck the INR
    • in urgent cases, administer KANAVIT + PCC (PROTHROMPLEX or FEIBA)  → see here
  • recheck INR before the procedure
  • restart warfarin after 12-24h; use either the standard maintenance dose or a double dose
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  • high risk of hematoma is associated with the therapeutic dose (5-10 mg/d); the risk at a prophylactic dose (2.5 mg/d) is relatively low
  • discontinue fondaparinux at a prophylactic dose (2.5 mg) 36-42 h before the puncture and resume it 6-12 hours later
  • there are no strict recommendations for discontinuing a full therapeutic dose (probably > 48h)
  • specific tests are available to detect the residual activity of fondaparinux  → Fondaparinux
  • heparin half-life is 1-2 hours
  • a lumbar puncture can be performed after > 4-6h (according to different recommendations) following the last heparin application, provided that the APTT ratio is normal (≤ 1.2)
  • heparin can be restarted 1-2 hours after the lumbar puncture (Dodd, 2018)
  • hemostatic dysfunction may persist for up to 24 hours following tPA administration (via IVT, IAT, or intrasinus thrombolysis)
    • postpone lumbar puncture for > 24h
    • fibrinogen levels can help assess coagulation status since fibrinogen is the last of the coagulation factors to normalize after thrombolysis
  • IVT administration < 10 days after a dural puncture is a relative contraindication – consider the risk-benefit ratio (AHA/ASA 2019 IIb/C)

LMWH bridging

  • warfarin
    • consider bridging only in high-risk patients (see table below)
    • meta-analyses have not shown a clear benefit of bridging, only an increased risk of bleeding
    • BRIDGE trial in Afib patients showed non-inferiority of no therapy vs. LMWH bridging (only a few patients with CHADS2 ≥ 5 were enrolled in this trial; CHA2DS2-VASc score was not used)
    • for patients with VTE lasting more than 3 months, a prophylactic dose of LMWH may be selected for bridging and should be discontinued 12 hours before surgery
    • LMWH at therapeutic dose in high-risk patients should be started when the INR is < 2 (usually 36h after warfarin discontinuation) and discontinued ≥ 24h before surgery/procedure
    • after the procedure, restart LMWH within 12-24h (at a therapeutic dose)
  • DOAC
    • bridging therapy during DOAC discontinuation is not necessary, given the drug’s half-life and short discontinuation period
High-risk patients ⇒ consider LMWH bridging
DVT (deep vein thrombosis / PE)
  • DVT/PE < 3 months
  • high-risk patient with a previous DVT on warfarin with a target INR of 3.5
Atrial fibrillation
  • stroke/TIA < 3 months
  • stroke/TIA > 3 months + risk factors (CHA2DS2-VASc score ≥ 3)
    • heart failure
    • hypertension with BP > 140/90 mm Hg
    • age > 75 years
    • diabetes
Mechanical valve

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Lumbar puncture and antithrombotic therapy