Assessing Donor and Platelet Transfusion Characteristics on Intracranial Hemorrhage Outcomes

Introduction: Intracranial hemorrhage (ICH) patients require rapid treatment to reverse coagulopathy, which can help establish hemorrhage control and improve outcomes. While acute platelet transfusions are given in ICH to reverse platelet dysfunction, delays in administration of hemorrhage control therapies and platelet unit characteristics themselves may impact the efficacy and clinical outcomes in different patient populations. Thus, we sought to evaluate the relationship of platelet transfusion timing and platelet unit characteristics with ICH mortality.

Methods: Available data for incident hospitalizations of adult ICH patients between 2019-2022 from 3 of the 5 participating sites within the multicenter REDS-IV-P network were assessed. ICH patients were included if they received ≥ 1 acute platelet transfusion within 48 hours of admission and presented with one of the following ICH etiologies: trauma (tICH), spontaneous intracerebral hemorrhage (sICH), and aneurysmal subarachnoid hemorrhage (aSAH). Patients with early withdrawal of care and death within the first 48 hours were excluded. Separate logistic regression models (each adjusting for age, sex, race/ethnicity, comorbidities, and number of platelet transfusions) assessed the relationship of 30 day ICH mortality outcome with the following: a) time to initial platelet transfusion in hour quartiles: <2.7 hours [reference] vs 2.7-5.6 hours vs 5.7-14.5 hours vs 14.6-48 hours, b) any major ABO incompatible platelet transfusion versus identical or minor mismatch, and c) any donor-recipient sex mismatched platelet transfusion. Separate subgroup analyses were performed by ICH etiologic subgroups.

Results: Amongst 619 ICH patients receiving an acute platelet transfusion, 52% were from tICH, 36% from sICH, and 12% from aSAH. Mortality was seen in 17% of the overall cohort. Longer times to platelet transfusion (longest quartile: 14.6-48 hours) were associated with mortality in the overall ICH cohort (adjusted OR 2.12; 95%CI: 1.10-4.12). In sICH, effect size estimates were notably greater with the longest quartile time to platelet transfusion also being associated with mortality (adjusted OR 4.66; 95%CI: 1.58-14.8). Longer times to platelet transfusion were not associated with mortality in tICH (adjusted OR 1.19; 95%CI: 0.45-3.15). Amongst 543 ICH patients with available donor-recipient ABO data, 32% received a major ABO incompatible platelet transfusion. While there was not an association of major ABO incompatible platelet transfusion with mortality in the overall cohort (adjusted OR 1.41; 95%CI 0.82-2.40), there again was a significant association of this exposure with mortality in the sICH subgroup (adjusted OR 3.06; 95%CI: 1.22-7.90). No associations of major ABO incompatible platelet transfusions were identified in tICH subgroup (adjusted OR 1.02; 95%CI: 0.49-2.10). We did not identify a relationship of sex mismatched platelet units with mortality in the overall ICH cohort or in any ICH subgroups.

Conclusions: In our analyses of data available from the REDS-IV-P network, we identified a suggestive relationship between longer times to platelet transfusion and mortality, but not of ABO mismatch in our overall ICH cohort. However, sICH may be a specific ICH subgroup more vulnerable to platelet transfusion characteristics and practices, particularly time to platelet transfusion and major ABO incompatible platelet unit exposures. Further work is necessary to assess the generalizability of our data and to clarify whether certain adult ICH patients require specially tailored platelet transfusion approaches.