Category: Critical Care
Keywords: DDAVP, desmopressin, ICH, intracranial hemorrhage, stroke, CVA, hyponatremia (PubMed Search)
Pearl: consider desmopressin (DDAVP) for patients with an intracranial hemorrhage who are taking an antiplatelet. Caution, this is not for patients with an ischemic stroke with hemorrhagic conversion and it was not specifically evaluated for patients on anticoagulation or going to the OR with neurosurgery.
How strong is this evidence? International guidelines already give cautious approval for this practice, and now there is a retrospective review to support it. Though there were only 124 patients in the trial, the rate of hemorrhage expansion was much lower in the DDAVP group (10.9% vs 36.2%, P = .002) and there was no increased risk of hyponatremia (no events reported).
Background: the USPSTF updated recommendations for aspirin for primary prevention of stroke, heart attack, and colon cancer to cut down on over prescription (it's no longer indicated if you're over 70 and it's a question of shared decision-making if you're over 60) but a staggering number of our patients will be on at least one anti-platelet drug when they present with an intracranial hemorrhage.
Past guidelines for treating the bleed in a patient on an anti-platelet drug have given guarded support to giving desmopressin (DDAVP), but some worried the potential for hyponatremia and worsening cerebral edema might outweigh the benefit of releasing von Willebrand Factor.
This study from Upstate University Hospital, Syracuse reviewed 124 cases of intracranial hemorrhage in patients on antiplatelets, but not on anticoagulation and not going to the OR. A total of 55 got DDAVP and 69 did not. The rate of hemorrhage expansion in the first 24 hours was much lower in the DDAVP group (10.9%) than the untreated group (36.2%), and without a significant difference in the rates of hyponatremiia (no events) or thrombotic events (though this last one trended toward more events in the DDAVP group at 7.3% compared to 1.4% in the untreated group).
Feldman E, Meola G, Zyck S, et al. Retrospective Assessment of Desmopressin Effectiveness and Safety in Patients With Antiplatelet-Associated Intracranial Hemorrhage. Critical Care Medicine 2019; 47(12):1759-1765.