Should platelet transfusion be used to reverse preinjury antiplatelet agents in traumatic brain injury? A systematic review and meta-analysis

INTRODUCTION: Platelet transfusion is a scarce resource in many trauma centers that is not without its own complications. Controversy exists in the literature regarding platelet transfusion in the setting of traumatic brain injury in patients on antiplatelet agents. METHODS: A search of the MEDLINE and Cochrane Reviews databases was used to identify all studies examining platelet transfusion and antiplatelet agents related to traumatic brain injury published from inception to March 2024. Study selection, data extraction, and bias assessment were conducted independently by two reviewers. Heterogeneity was assessed via I2 statistic, and publication bias was evaluated using Newcastle Ottawa Scale for cohort studies. A meta-analysis was performed to estimate pooled treatment effects with 95% confidence intervals (CIs). RESULTS: Of the 131 studies initially identified, 11 studies met the inclusion criteria comprising 1,326 patients who received platelet transfusion and 5,391 patients who did not. Across studies, patients receiving platelets were more severity injured than those who did not (mean Glasgow Coma Scale, 13.4 ± 0.44 vs. 14.2 ± 0.26; mean Injury Severity Score, 20.7 ± 0.9 vs. 18 ± 3.4). Pooled analysis found that receiving platelet transfusion did not significantly change the likelihood of mortality or hemorrhage progression (odds ratio, 1.40; 95% CI, 0.72-2.71; odds ratio, 1.09; 95% CI, 0.37-3.20, respectively). Both length of stay (LOS) and intensive care unit LOS were found to be significantly longer with platelet transfusion (2.2 days longer: 95% CI, 2.07-2.32; 3.06 days longer: 95% CI, 2.0-4.13). CONCLUSION: The results currently available in the literature do not support the routine reversal of preinjury antiplatelet agents for reducing mortality or hemorrhage progression. Furthermore, the use of platelet transfusion in these patients may unnecessarily prolong intensive care unit and hospital LOS. This meta-analysis provides justification for randomized-controlled trials investigating the effects of platelet transfusion in head-injured patients on preinjury antiplatelet agents. Obtaining higher level of evidence will expedite the creation of high-quality evidence-based guidelines for the management of these complex patients. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level IV.