Platelet transfusions and outcomes following minimally invasive intracerebral hemorrhage evacuation

OBJECTIVE Minimally invasive evacuation has emerged as a promising treatment paradigm for spontaneous intracerebral hemorrhage (ICH). Preoperative platelet transfusion to reduce the risk of perioperative hemorrhage remains controversial, given that it can increase clot fibrosity, leading to a more difficult-to-resect hematoma and worse clinical outcome without appreciably reducing the risk of perioperative hemorrhage. To evaluate this hypothesis, the authors developed and prospectively applied a qualitative scale rating the consistency of intraoperative hematoma and then assessed the association of the scale with platelet transfusion, evacuation percentage, functional outcome, and postoperative rebleeding. METHODS Patients presenting with spontaneous supratentorial ICH at a large urban healthcare system from October 2017 to December 2021 were evaluated for surgical evacuation. Criteria for study inclusion comprised age ≥ 18 years, premorbid modified Rankin Scale (mRS) score ≤ 3, hematoma volume ≥ 15 mL, and National Institutes of Health Stroke Scale score ≥ 6. Intraoperatively, clots were prospectively assigned a consistency score, ranging from 1 to 5. A score of 1 indicated a completely fluid hematoma; a score of 2, a hematoma with solid components requiring only aspiration for removal; and scores of 3 and 4, a hematoma with solid components requiring morcellation in addition to aspiration for removal. If ≤ 50% of the clot required morcellation, a score of 3 was assigned. If > 50% of the clot required morcellation, a score of 4 was assigned. A score of 5 indicated fibrous clot resistant to both aspiration and morcellation. RESULTS The study included 142 consecutive patients. The median clot consistency score was 2 (IQR 2–3). A higher clot consistency score was associated with a lower evacuation percentage, which in turn was associated with worse 9-item modified Rankin Scale questionnaire (mRS-9Q) scores at 6 months. The only preoperative factors independently associated with clot consistency were platelet transfusion (β = 0.92, 95% CI 0.21–1.64, p = 0.01) and anticoagulant reversal (β = 1.27, 95% 0.60–1.94, p = 0.0003). Specifically, the median clot score was 4 (IQR 2–5) and 4 (IQR 2–4) among these patients, respectively, but only 2 (IQR 2–2) among the remainder of the cohort (p < 0.0001). Platelet transfusion and anticoagulant reversal were in turn associated with greater residual hematoma volumes, lower evacuation percentages, and worse 6-month mRS-9Q scores but not with lower rates of postoperative rebleeding. Specifically, the median 6-month mRS-9Q score was 6 (IQR 4–6) and 5 (IQR 4–6) among these patients but 3 (IQR 3–5) among the remainder of the cohort (p < 0.0001). CONCLUSIONS In a prospective cohort of 142 patients undergoing minimally invasive endoscopic ICH evacuation, the preoperative administration of platelets was associated with increased clot fibrosity, reduced technical success, and worse clinical outcomes but not with postoperative rebleeding. Among patients taking antiplatelets, preoperative platelet transfusions should be avoided to optimize technical efficacy and clinical outcomes.