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Desmopressin acetate in intracranial haemorrhage.

1. Introduction

Platelet aggregation inhibitors such as acetylsalicylic acid, adenosine diphosphate (ADP) receptor inhibitors, and vitamin K antagonists are a fixed constant in the treatment of acute and chronic atherothrombotic vascular diseases, including myocardial infarction, acute coronary syndrome, peripheral arterial obstructive disease, and atrial fibrillation [1, 2]. The prescribing data for platelet aggregation inhibitors and sales figures for acetylsalicylic acid suggest that their use is becoming more widespread (Figure 1) [3]. Their prescription and use are dependent on comorbidities and age, however, which can increase the attendant risk of haemorrhage [1].

These drugs, which are being used increasingly in the elderly, are of neurological importance in the event of intracranial haemorrhage, for instance. The types of intracranial haemorrhage deserving special mention are intracerebral, acute, and chronic subdural haemorrhage, and spontaneous subarachnoid haemorrhage.

Approximately 20% of all patients admitted with traumatic brain injury are found to have acute subdural haematoma, which primarily occurs between the age of 31 and 47 years. The mortality rate can exceed 75% [4]. Out of 100,000 patients, 10-30 suffer spontaneous intracerebral haemorrhage. The incidence of intracerebral haemorrhage associated with strokes is approximately 15%. The elderly are more likely to suffer intracerebral haemorrhage than younger individuals. The treatment outcome depends on the extent and localisation of the haemorrhage [5]. Chronic subdural haematoma (Figure 2) is one of the most common forms of traumatic intracranial haemorrhage [6] and is often caused by a mild traumatic incident only seldom recalled by the patient [7]. Common to all these types of haemorrhage is the fact that more extensive and prolonged bleeding, as well as a greater risk of secondary haemorrhaging, can be expected if the patient is already taking a platelet aggregation inhibitor [8, 9] (Figure 3).

When faced with the dilemma of prohemostatic measures for minimising the complications of intracranial haemorrhage and an indication for platelet aggregation inhibition, the question of the best possible treatment arises. Desmopressin acetate, which is known to attenuate the effect of acetylsalicylic acid, has been studied in cardiac diseases [10-14]. Desmopressin (1-deamino-8-d-arginine vasopressin) increases plasma factor levels due to the endogenous release of coagulation factor VIII (FVIII), von Willebrand factor (vWF) and tissue plasminogen activator (tPA), enhanced platelet adhesion, and reduced bleeding time [10-13,15]. The exact mechanism of action of acetylsalicylic acid, however, has not been fully explained.

Here we discuss the possibility of attenuating the effect of acetylsalicylic acid based on an observational study in patients with intracranial haemorrhage.

2. Patients and Methods

The local ethics committee approved the laboratory and haematological tests in patients with traumatic brain injury and impaired consciousness.

2.1. Patients. Between 2008 and 2014, patients who had been admitted for acute intracranial haemorrhage and were already using acetylsalicylic acid, along with control patients, were enrolled in the study. Enrolment depended on the possibility to perform laboratory tests and so took place only during the day rather than at night and also depended on the availability of suitable patients, who were selected if they were available for analysis between 8.00 a.m. and 3.30 p.m. In addition, patients were only enrolled by three neurosurgical members of the study team.

The inclusion criteria required patients to be over 18 years of age and have a diagnosis of isolated spontaneous or traumatic intracranial haemorrhage confirmed by computed tomography. The haemorrhage alone had to be a correlate of a neurological deficit such as coma, hemiparesis, or aphasia and thus presents a surgical indication, or the progressive size had to suggest that a clinically relevant deterioration was likely (compression of basal cisterns, midline shift). A further inclusion criterion was evidence (communicated personally or in writing) of the intake of acetylsalicylic acid within 24 hours prior to admission.

The exclusion criteria comprised intake of other anticoagulants or platelet aggregation inhibitors, known coagulation disorders, alcoholism, known hypercoagulable tendency, renal failure, hypothermia (<35[degrees]C), multiple trauma, or polytrauma.

In doing so, a distinction was made between patients having taken acetylsalicylic acid once within 24 hours prior to admission ([Pat.sub.SIN]) and those having taken the drug regularly (daily) or more than once ([Pat.sub.MUL]). Patients who were conscious could be questioned; otherwise, information was taken from the records of other hospitals, documentation from previous stays at our hospital, or documentation obtained from a care facility or the general practitioner. Patient details are provided in Table 1.

The control group comprises 3 patients (one woman aged 52 years with spontaneous subarachnoid haemorrhage; one man aged 79 years with traumatic brain injury; one man aged 56 years with traumatic brain injury). Since--unlike the patients with intracranial haematoma--predominantly normal values were found initially and the values for platelet aggregation inhibition were normal, no further blood tests were performed over the course.

All patients were monitored intensively for intracranial haemorrhage and their potential (cardiac and circulatory) risks following administration of desmopressin.

2.2. Desmopressin Acetate and Platelet Function Tests. There are numerous recommendations to also use desmopressin acetate as a treatment for platelet function disorders or mild thrombocytopenia. Desmopressin acetate is used to improve primary haemostasis--not because of the enhanced aggregability of the platelets, but rather due to their increased adhesiveness [16].

Platelet function was tested using platelet function analysis (PFA-100, Dade Behring, Germany), which measures the time required for a platelet plug to form and seal a semipermeable membrane. This membrane is coated in collagen. As under physiological conditions, it serves as an initial matrix for platelet adhesion in relation to the von Willebrand factor found in the tested blood. During the test, the platelets bind directlywith the collagen, which in turn leads to platelet activation. Adherent platelets are degranulated on contact with the agonists' epinephrine and adenosine phosphate, which are also found in the membrane. Activation of free-flowing platelets and blood clot aggregation is the outcome. Consequently, the opening in the membrane gradually closes (Figure 4) [17]. The standard values for membrane closure range from 68 to 120 seconds for adenosine phosphate and 54 to 165 seconds for epinephrine. The uneventful use of PFA-100 in neurosurgical patients is documented in the literature [18].

2.3. Test Points. Platelet function was analysed prior to administration of desmopressin (T1). Desmopressin acetate was administered over a period of 30 minutes so as to avoid flushing and hypotension. The platelet function was then analysed half an hour (T2) and three hours (T3) after administration. All patients were given 24 [micro]g in 100 mL physiological saline solution over a period of 30 minutes. The time between sampling and starting the test was less than 15 minutes and did not hinder the procedures with respect to potential surgery.

Statistical analysis comprised the Wilcoxon and Mann-Whitney U tests, with a significance level of P [less than or equal to] 0.05.

3. Results

During the specified period, 10 patients on acetylsalicylic acid with the following conditions were enrolled: intracerebral haemorrhage (N = 3), cerebral infarctions (N = 2), traumatic brain injury with contusion or acute subdural haematoma (N = 2), spontaneous subarachnoid haemorrhage with hydrocephalus (N = 1), and chronic subdural haemorrhage (N = 2). Acetylsalicylic acid had been taken once by 4 patients and multiple times by 6 patients. Three patients were recruited as controls (Table 1). Seven of these 10 patients underwent surgery immediately after admission ([Pat.sub.SIN] N = 3, [Pat.sub.MUL] N = 4); the remaining 3 patients were monitored under intensive care conditions.

The exact dose of acetylsalicylic acid could not always be determined, especially in those patients having taken only one dose. In the others, the dose did not exceed 100 mg.

(1) The platelet function was found to be impaired in both patient groups ([Pat.sub.SIN] and [Pat.sub.MUL]) at T1. Figures 5 and 6 illustrate the mean membrane occlusion times for time point T1, with results exceeding the norm of 120 seconds (adenosine phosphate) and 165 seconds (epinephrine).

(i) In the adenosine phosphate samples, the mean time at T1 was 122.7 seconds (SD 21.8) for [Pat.sub.SIN] and 126.6 seconds (SD 89.0) for [Pat.sub.MUL] (P = 0.394).

(ii) The epinephrine samples revealed a mean occlusion time at T1 of 249.5 seconds (SD 59.94) for [Pat.sub.SIN] (P = 0.068).

(2) The mean value at T1 in the epinephrine tests was more than 300 seconds for [Pat.sub.MUL] (Figure 5).

(3) Platelet function had returned to normal or close to normal in both groups at T2 after administration of desmopressin acetate (Figures 5 and 6).

(i) In the adenosine phosphate samples, the mean time at T2 was 86.3 seconds (SD 32.06) for [Pat.sub.SIN] and 73.83 seconds (SD 9.45) for [Pat.sub.MUL] (P = 0.831).

(ii) The epinephrine samples revealed a mean occlusion time at T2 of 170.5 seconds (SD 92.16) for

[Pat.sub.SIN] and 192.8 seconds (SD 92.86) for [Pat.sub.MUL] (P = 0.829).

(4) The platelet function was again impaired in both groups at T3, though the values were worse in the [Pat.sub.MUL] group under epinephrine (Figures 5 and 6).

(i) In the adenosine phosphate samples, the mean time at T3 was 99.5 seconds (SD 30.73) for [Pat.sub.SIN] and 86.3 seconds (SD 7.91) for [Pat.sub.MUL] (P = 0.829).

(ii) The epinephrine samples revealed a mean occlusion time at T3 of 234 seconds (SD 83.53) for [Pat.sub.SIN] and 212.7 seconds (SD 94.78) for [Pat.sub.MUL] (P = 0.998).

(5) There were no relevant deviations from the reference values in the control group: mean ADP was 106 seconds (SD 18.5) and epinephrine 135,6 seconds (SD 16.5). There was one case of a relevant, secondary increase in intracranial haemorrhage with clinical deterioration. Surgery was not, however, indicated at any time.

No intraoperative bleeding complications or fluid or electrolyte imbalances were observed. No blood transfusions or reoperations were performed in this small cohort. The mean serum sodium and potassium levels, as well as urine volume, remained within the reference range or remained clinically irrelevant and so did not necessitate intervention.

4. Discussion

Taking traumatic brain injury as an example, there have been numerous reports of expansion in intracerebral haemorrhage within hours to days without the additional influence of external factors [19, 20]. Impaired coagulation in traumatic brain injuries is reported at an incidence of up to 26% [21]. Survival and outcome after traumatic brain injury depend on any expansion in the preexisting haemorrhage [20]. Haemorrhagic volume also plays an influential role in survival in the case of spontaneous intracerebral haemorrhage. The more extensive the haemorrhage, the poorer the treatment outcome when measured on the Glasgow Outcome Scale [20].

Bleeding tendency can be increased by prior treatment with acetylsalicylic acid. Desmopressin acetate is capable of significantly reducing blood loss and thus minimising the haemorrhagic risk [12, 14, 20].

As an antihemorrhagic agent with enhanced factor VIII coagulation activity, desmopressin acetate is authorised for use before surgery and tooth extraction and after traumas in mild to moderate haemophilia A and von-Willebrand-Jurgens disease [16]. However, paradigms are constantly shifting and there is still a shortage of data. There have been no reports of approval with respect to stabilising the platelet function in intracranial haemorrhage or prior to intracranial interventions following intake of acetylsalicylic acid. Aspirin has been identified as an independent predictor for death in patients suffering spontaneous intracranial haemorrhage [9].

We found that desmopressin acetate is a safe way to stabilise the platelet function in patients with intracranial haemorrhage if they are only taking acetylsalicylic acid.

We were not able to determine the exact dose of acetylsalicylic acid or the exact time between intake and administration of desmopressin acetate. However, this matter displays daily clinical life in which decisions must be done on the basis of just little information. Hence, our results must be understood within mentioned conditions.

The platelet function tended to return to normal relatively rapidly, that is, after 30 minutes, using a dose of 24 [micro]g. As a rule, this corresponds to the time it takes to admit the patient and prepare for emergency surgery. No electrolyte or fluid imbalances were found in our patient population. However, the platelet function deteriorates over the further course. Nevertheless, the question whether to administer desmopressin acetate immediately after diagnosing intracranial haemorrhage under acetylsalicylic acid or whether to only apply the drug preoperatively remains unanswered. Further studies must be conducted to verify the benefit of intranasal or intravenous administration of desmopressin acetate [22, 23].

We recommend administration of desmopressin in intracerebral haemorrhage so as to improve the coagulation status, as described in the literature (20 kg body weight = approximately 8 [micro]g, 50 kg body weight = approximately 20 [micro]g, 100 kg body weight = 40 [micro]g, or 0.3 [micro]g/kg body weight), followed by monitoring of the electrolyte and fluid balance [16, 24] in order to optimise the surgical setting.

Administration of platelet concentrates can be considered after applying desmopressin acetate; we would not recommend it, however, due to a lack of data [25-28]. Prolongation of normal platelet function is not immediately apparent as a result, and a more profound benefit would also appear doubtful given the fact that desmopressin acetate itself can stabilise the platelet function. Simultaneous administration of tranexamic acid should stabilise the blood clot, but further studies should be conducted [29].

5. Conclusion

Desmopressin acetate can improve the platelet function after 30 minutes in intracranial haemorrhage following acetylsalicylic acid intake. The coagulative status can thus be restored to normal levels in terms of platelet function for between 30 minutes and 3 hours. When administering desmopressin acetate in intracranial haemorrhage under acetylsalicylic acid, cardiac function, electrolyte, and fluid balance must be closely monitored.

http://dx.doi.org/10.1155/2014/298767

Disclosure

Parts of the study were presented at the Annual Meeting of the German Society of Neurosurgeons 2011.

Conflict of Interests

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge, and beliefs) in the subject matter or materials discussed in this paper.

Authors' Contribution

Thomas Kapapa designed the study, included and treated patients, drafted the paper, and revised the paper. Stefan Rohrer included and treated patients and reviewed the paper. Sabine Struve designed and supervised the laboratory test concept. Matthias Petscher treated patients and revised the paper. Ralph Konig included patients in the study. Christian Rainer Wirtz interpreted the data and prepared and revised the paper. Dieter Woischneck designed the study, included patients, supervised the study, and reviewed the paper.

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Thomas Kapapa, (1) Stefan Rohrer, (1) Sabine Struve, (2) Matthias Petscher, (3) Ralph Konig, (1) Christian Rainer Wirtz, (1) and Dieter Woischneck (4)

(1) Neurochirurgische Klinik, Universitatsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany

(2) Klinik fur Hamatologie, Onkologie, Immunologie, Palliativmedizin, Infektiologie und Tropenmedizin, Stadtisches Klinikum Munchen, Klinikum Schwabing, Kolner Platz 1, 80804 Munchen, Germany

(3) Klinik fur Anasthesiologie, Abteilung Klinische Anasthesiologie, Albert-Einstein-Allee 23, 89081 Ulm, Germany

(4) Neurochirurgische Klinik, Klinikum Landshut, Robert-Koch-Strasse 1, 84034 Landshut, Germany

Correspondence should be addressed to Thomas Kapapa; thomas.kapapa@uniklinik-ulm.de

Received 29 August 2014; Revised 28 November 2014; Accepted 8 December 2014; Published 23 December 2014

Academic Editor: Jeff Bronstein

TABLE 1: Characteristics of the patient population. Cerebral
infarction = CI, spontaneous subarachnoid haemorrhage = SAH,
spontaneous intracerebral haemorrhage = ICH, chronic subdural
haematoma = cSDH, traumatic brain injury = TBI, and
sodium = mmol/L.

(a) Multiple doses

Gender   Age   Weight   Height   Cause      Sodium       Surgery
                (kg)     (cm)            (prior/after)

M        72      85      179      ICH       139/138        Yes
M        52      73      179      TBI       135/140        No
M        72      85      180      ICH       134/132        Yes
M        72      81      164      ICH       139/139        No
M        52      65      179     cSDH       138/133        Yes
M        66      89      160      CI        136/139        Yes

(b) Single dose

Gender   Age   Weight   Height   Cause      Sodium       Surgery
                (kg)     (cm)            (prior/after)

F        44      59      165      CI        137/137        Yes
M        49      80      180      SAH       132/132        Yes
M        76      70      175      TBI       128/134        No
M        80      80      170     cSDH       142/142        Yes

(c) Control group

Gender   Age   Weight   Height   Cause      Sodium       Surgery
                (kg)     (cm)

M        79      87      174      TBI         142          No
M        56      79      176      TBI         138          No
F        52      62      168      SAH         136          Yes
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Title Annotation:Research Article
Author:Kapapa, Thomas; Rohrer, Stefan; Struve, Sabine; Petscher, Matthias; Konig, Ralph; Wirtz, Christian R
Publication:Neurology Research International
Article Type:Report
Date:Jan 1, 2014
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