Intracranial hemorrhage (ICH) is a common complication in patients with acute leukemia and is associated with significant morbidity and mortality. Information on platelet transfusion practice in patients following ICH is limited, so researchers assessed clinical features and outcomes to better guide transfusion practices after ICH. Shannon Nixon, NP, of the Princess Margaret Cancer Centre at the University of Toronto, discussed the findings at the ASH Annual Meeting on December 3, 2018.
The retrospective study included adult patients diagnosed with acute leukemia who had documented ICH at a large, quaternary, academic cancer center between January 1, 2009, and December 31, 2016. Researchers assessed demographics, medications, infection and bleeding history in the week prior to ICH, characteristics of ICH, acute management, transfusion practice in the first 90 days, and clinical outcomes. They also assessed radiologic scans to determine whether ICH was stable or if new or progressive bleeding had developed.
Of the 2,576 identified patients, 101 had an ICH. Most patients (n = 94) had AML, including acute promyelocytic leukemia (n = 9), acute lymphocytic leukemia (n = 6), and mixed phenotype acute leukemia (n = 1). At the time of ICH, 61 patients were newly diagnosed or receiving induction chemotherapy, 33 had relapsed disease, and seven were in complete remission. Many patients (n = 76) experienced spontaneous ICH. In the week preceding ICH, seven patients received medications that are known to increase bleeding risk and 39 received tranexamic acid. Researchers observed clinical evidence of bleeding elsewhere in 64 patients and evidence of infection in 22 patients.
On the day of the ICH event, most patients had active disease. The median platelet count was 16 × 109/L (range = 0–433 × 109/L). Almost a third of patients (n = 31) had a platelet count less than 10 × 109/L, and 10 patients received a platelet transfusion prior to the bleed. Of the 70 patients who had a platelet count ≥ 10 × 109/L, 17 received a platelet transfusion prior to the bleed. Six patients (6%) were refractory to platelet transfusion.
In the 90 days following ICH, platelet transfusions were administered for platelet counts of:
- Less than 10 × 109/L (21%)
- Between 10 × 109/L and 29 × 109/L (55%)
- 30 × 109/L or greater (24%)
Twenty-eight patients experienced new or progressive ICH.
The median platelet transfusion threshold was 19 × 109/L (range = 0–114 × 109/L) for those without new or progressive ICH and 21×109/L (range = 0–93 × 109/L for those with progression (p = 0.04).
Seventy-nine patients died, although most (n = 65; 82%) deaths were attributed to non-ICH causes. The median overall survival was 5.6 months for those without new or progressive ICH compared to 2.9 months for those with progression (p = 0.002).
“Platelet transfusion practice was variable, and the median threshold was higher in those who subsequently developed new or progressive bleeding,” the researchers noted. Although the reasons were unclear, the investigators hypothesized additional risk factors, such as fever or infection, may have contributed.