Written by Clay Smith
Lumbar puncture (LP) in this small cohort of patients taking dual antiplatelet therapy was not associated with an increased risk of complications. I would still proceed with caution in such patients.
Why does this matter?
Dual antiplatelet therapy is a relative contraindication to LP. Prior studies have shown it is safe in up to 300 patients on single antiplatelet therapy. If you really needed CSF, could it still be performed safely on dual treatment?
They got lucky
This was a case series of 100 patients on dual antiplatelet therapy who underwent LP. Most were taking aspirin 81mg plus clopidogrel 75mg. They found no complications of epidural hematoma, and the risk of traumatic tap (100 RBCs per microliter) or grossly bloody tap was 8% and 4% respectively, which is near baseline for LP attempts overall. Almost all were performed in an outpatient setting by highly experienced providers. In fact, most were "LP nurses" with vast experience. The authors acknowledge that this was a small study but conclude that LP appears to be safe. I am very uneasy about this on the basis of such a small study. Epidural hematoma is a rare complication, and it would likely take a much larger sample size to find out the answer to this question. It is also simply a retrospective case series, with no comparison group. It would take a very compelling indication for me to do a LP in a patient on dual antiplatelet therapy, despite this reassurance.
Safety of Lumbar Puncture Performed on Dual Antiplatelet Therapy. Mayo Clin Proc. 2018 May;93(5):627-629. doi: 10.1016/j.mayocp.2018.02.005. Epub 2018 Mar 22.
- EmCrit also offers a cautionary review of LP on clopidogrel or dual agents.
- ALiEM has a broader review of LP in anticogulated patients.
Reviewed by Thomas Davis