ADD-ONS / MEDICATION

Lumbar puncture and antithrombotic therapy

Created 07/02/2022, last revision 12/02/2022

  • lumbar puncture (LP) is an important and frequently performed invasive procedure for the diagnosis and management of many neurological
    conditions
  • the procedure is associated with a certain risk of spinal bleeding (most often epidural hematoma)
  • higher-risk conditions include:
    • coagulopathies (including pharmacologically induced)
    • older age
    • multiple puncture attempts
    • 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 in case of sudden sensorimotor, sphincter deficits, or severe low back pain following the puncture ⇒ perform MRI immediately and consult a neurosurgeon ( after > 8 h, the prognosis is already unfavorable despite successful surgery!) [Herlocker, 2010]
  • on the other hand, periprocedural discontinuation of antithrombotic medication is associated with the increased risk of thromboembolism
  • the potential benefit of lumbar puncture must always outweigh the risk of thrombosis
  • bridging therapy may be necessary for high-risk patients
  • consultation with the specialist who indicated the antithrombotic drug and a hematologist is advisable

Coagulopathies

Routine coagulation and CBC
  • routine CBC + coagulation tests are performed before lumbar puncture; however, this is not explicitly stated in the recommendations in patients with negative history of bleeding or hepatopathy
  • always perform in patients:
    • with known coagulopathy or history of bleeding
    • using anticoagulant therapy
    • with hepato- or nephropathy
  • consult a hematologist if pathological results are obtained
Thrombocytopenia
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Inherited coagulopathies
  • always manage such patients in cooperation with a hematologist
  • caution is necessary for patients with a positive family history who have not yet been diagnosed

Antiplatelet therapy

Aspirin
  • low-dose ASA (100 mg) does not increase the risk of bleeding in minor procedures (incl. lumbar puncture), nor has it been found to increase the risk of bleeding in epidural anesthesia (ASA given because of pre-eclampsia) ⇒ no need to discontinue ASA
  • only high doses of ASA (> 300 mg) likely 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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Others
  • discontinue cilostazol 42h before the procedure, restart after  5h    [Gogarten, 2010]
  • dipyridamole has a half-life of 10-12h, no specific precautions are needed, it can be restarted after 6h

Urgent reversal of antiplatelet drugs effect

  • prophylactic reversal of antiplatelet drugs effect is not a routine procedure and rather should be avoided (risk of thrombosis)
  • 2-3 units of platelets may be considered (provides functional, circulating platelets), consult a hematologist
    • studies have shown mixed results regarding the benefit of this practice, there is no standard dose,  no effect has been demonstrated in the PATCH trial
  • desmopressin (ddAVP) OCTOSTIM – 0,3 ug/kg +100 mL of NS, infusion over 15-30 min 
    • benefit unproven when used before lumbar puncture, data available for general surgery only (reduced need for transfusion) (Desborough, 2016)

Anticoagulant therapy and thrombolysis

→ periprocedural discontinuation of the anticoagulant therapy

Warfarin
  • it is safe to  perform LP if INR is ≤ 1.4
  • discontinue warfarin 4-5 days before the procedure – the drop in INR is individual and difficult to predict
    • the rapid fall in INR in the first 3 days after warfarin discontinuation reflects the rise in factor VII activity, but hemostasis may continue to be worse due to f. II and X deficiency (they take longer to normalize) [Herlocker, 2010]
    • if early LP is required, administer KANAVIT 5 mg IV  > 6-8 h before the procedure, then check INR
    • for urgent indication administer KANAVIT + PCC (PROTHROMPLEX. FEIBA)  → see here
  • check INR before the procedure
  • restart warfarin after 12-24h – standard maintenance dose or double dose can be used
DOAC
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LMWH
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Fondaparinux
  • high risk of hematoma is present in therapeutic dose (5-10 mg/d), the risk of prophylactic dose (2.5 mg/d) is relatively low
  • discontinue fondaparinux in prophylactic dose (2.5 mg)  36-42 h before the puncture, reintroduce in 6-12 h
  • there are no strict recommendations for full therapeutic dose (probably > 48h)
  • specific tests are available for detection of fondaparinux residual activity  → fondaparinux
Heparin
  • heparin has a half-life of 1-2 h
  • a lumbar puncture can be performed > 4-6h (according to different recommendations) after the last heparin application, provided that the  APTT ratio is normal (≤ 1.2)
Thrombolysis
  • after IVT (as well as after IAT or intrasinus thrombolysis), the hemostatic disorder can persist for up to 24 h
    • postpone lumbar puncture > 24h
    • fibrinogen levels can be helpful (after thrombolysis, it is the last of the coagulation factors to get normalized)
  • IVT administration < 10 days after a dural puncture is a relative contraindication – consider risk-benefit (AHA/ASA 2019 IIb/C)

LMWH bridging

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