Lumbar puncture and antithrombotic therapy

Created 07/02/2022, last revision 25/05/2023

lumbar puncture (LP), also known as a spinal tap, is an important and commonly performed invasive procedure to obtain cerebrospinal fluid (CSF) for diagnostic testing
the procedure is associated with some risk of spinal bleeding (most often epidural hematoma)
high-risk conditions include:
- coagulopathies (including pharmacologically induced)
- advanced 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 the case of sudden sensorimotor and/or sphincter deficits or severe low back pain 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 is associated with an increased risk of thromboembolism
- 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 required in high-risk patients
consultation with the specialist who ordered the antithrombotic therapy and a hematologist is recommended

Routine coagulation and CBC

routine CBC + coagulation tests are performed prior to lumbar puncture; however, this is not explicitly stated in the recommendations for patients with a negative history of bleeding or hepatopathy
always perform in patients:
- with known coagulopathy or a history of bleeding
- on 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 collaboration with a hematologist
caution is necessary for patients with a positive family history who have not yet been diagnosed

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 during epidural anesthesia (ASA given for pre-eclampsia) ⇒ no need to discontinue ASA
only high doses of ASA (> 300 mg) 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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Others

discontinue cilostazol 42h before the procedure and restart after 5h [Gogarten, 2010]
dipyridamole has a half-life of 10-12h; no special precautions are needed – it can be resumed after 6h

prophylactic reversal of antiplatelet therapy 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 and no effect was shown 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 only available for general surgery (reduced need for transfusion was reported) (Desborough, 2016)

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
- in urgency, 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 at the therapeutic dose (5-10 mg/d); the risk at a prophylactic dose (2.5 mg/d) is relatively low
discontinue fondaparinux in prophylactic dose (2.5 mg) 36-42 h before the puncture, resume in 6-12 h
there are no strict recommendations for a full therapeutic dose (probably > 48h)
specific tests are available to detect the residual activity of fondaparinux → 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)
heparin can be restarted 1-2 h after LP (Dodd, 2018)

Thrombolysis

after IVT (as well as after IAT or intrasinus thrombolysis), the hemostatic dysfunction may persist for up to 24 hours
- postpone lumbar puncture > 24h
- fibrinogen levels can be helpful (it is the last of the coagulation factors to normalize after thrombolysis)
IVT administration < 10 days after a dural puncture is a relative contraindication – consider risk-benefit (AHA/ASA 2019 IIb/C)

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