|Year : 2019 | Volume
| Issue : 2 | Page : 104-106
Platelet-rich plasma protocols can potentiate vascular emboli: Contraindications to platelet-rich plasma
Prathap Jayaram1, Peter C Yeh2, John Cianca3
1 H. Ben Taub Department of Physical Medicine and Rehabilitation; Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
2 H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
3 H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine; Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, Houston; Human Performance Center, Bellaire, TX, USA
|Date of Submission||02-Jan-2019|
|Date of Acceptance||02-Mar-2019|
|Date of Web Publication||29-Aug-2019|
Dr. Prathap Jayaram
Baylor College of Medicine, Houston, TX
Source of Support: None, Conflict of Interest: None
Platelet-rich plasma (PRP) is a regenerative therapy strategy used to address surgical wounds, dermatological conditions, and musculoskeletal conditions, such as lateral epicondylosis. However, there exists significant uncertainty and speculation about antiplatelet agents' effects on PRP and optimal approaches to cessation of agents such as aspirin prior to PRP therapy. We present a rare case report that provides an example of temporary antiplatelet agent cessation complications in the context of a PRP therapy regimen for lateral epicondylosis, which was followed by microemboli to the brain. Given Class B evidence for PRP for lateral epicondylosis, we feel that this case of a nontraumatic brain injury sequelae can present more frequently given the increased popularity of this regenerative strategy, particularly if certain precautions are not evaluated.
Keywords: Emboli, lateral epicondylosis, platelet-rich plasma, regenerative medicine
|How to cite this article:|
Jayaram P, Yeh PC, Cianca J. Platelet-rich plasma protocols can potentiate vascular emboli: Contraindications to platelet-rich plasma. J Int Soc Phys Rehabil Med 2019;2:104-6
|How to cite this URL:|
Jayaram P, Yeh PC, Cianca J. Platelet-rich plasma protocols can potentiate vascular emboli: Contraindications to platelet-rich plasma. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2021 Sep 17];2:104-6. Available from: https://www.jisprm.org/text.asp?2019/2/2/104/265265
| Introduction|| |
Platelet-rich plasma (PRP) is a regenerative therapy strategy that has gained significant traction within musculoskeletal applications, including treatment for lateral epicondylosis; however, there exists significant uncertainty and speculation about antiplatelet agents' effects on PRP, and optimal approaches to cessation of agents such as aspirin prior to PRP therapy. Aspirin used alone or in combination with clopidogrel can reduce the risk of myocardial infarction, ischemic stroke, and other cardiovascular events such as acute coronary syndrome; nevertheless, due to the inherent bleeding possibility while on aspirin, risk and benefits evaluation of holding aspirin prior to a procedure is recommended. For instance, the bleeding risk associated with oral, periodontal, and implant dental surgery are not as high and can be controlled locally, thus ceasing aspirin consumption prior to such surgery is not recommended. Meanwhile, refraining aspirin therapy prior to hip surgery is recommended as aspirin consumption can increase hemorrhage and blood transfusion needs. Evidence exists to indicate that PRP growth factor release depends on platelet aggregation, which nonsteroidal anti-inflammatory drugs such as aspirin inhibit., This is a desirable therapeutic intervention when reducing atherosclerotic cardiovascular disease risk, but undesirable if one seeks to utilize PRP for regenerative purposes. Our case provides an important example of temporary antiplatelet agent cessation complications in the context of a PRP therapy regimen.
| Case Report|| |
The patient was a 59-year-old gentleman with medical history significant for hyperlipidemia and Grade 3 mitral valve prolapse status post mitral valvuloplasty, now on aspirin 324 mg for prophylaxis.. His primary care physician referred him for an evaluation of suspected tennis elbow. At the outpatient physiatry practice, physical examination was consistent with elbow extensor tendinopathy, and the patient was informed of PRP therapy. The risks, benefits, and alternatives were explained to the patient, and he endorsed understanding and wished to pursue PRP therapy. He was informed that he should confirm with his cardiologist if the protocol to hold aspirin for 1 week prior to and 3 weeks after receiving PRP therapy was safe. He was an otherwise healthy male who was retired and maintained a high level of well-being – swimming 2 km daily, playing tennis multiple times weekly, and adhering to a low-fat high-protein diet. His other medications included niacin, atorvastatin, and diphenhydramine for sleep.
The patient stopped aspirin without consulting his cardiologist and did not disclose this to the treating physician. He returned to physiatry clinic 1 week after ceasing aspirin and underwent an ultrasound-guided PRP injection to his affected elbow without any immediate complications. The PRP formulation was not known. Ten days postprocedure, the patient began experiencing progressively worsening lightheadedness which escalated to daily headaches. Two-week postprocedure, his headaches worsened and became associated with severe anxiety. He recalled acute paranoia, restlessness, and disorientation. This was accompanied by impulsive behaviors, including aimlessly wandering outside his neighborhood late at night and driving for no discernable reason. The symptoms peaked with massive depression, and the first set of focal symptoms was left arm and leg numbness. The patient recognized these symptoms as heralding a stroke and resumed daily 81 mg aspirin. He subsequently saw his primary care physician who referred him to a neurologist. Prior to his neurology appointment, the patient's numbness recurred. He visited an emergency department where a work up including computed tomography of the head and blood work with anticoagulant profile was negative. He was discharged with a diagnosis of peripheral neuropathy.
At his first neurology appointment, the patient was suspected to have had a microembolic shower event and was started on clopidogrel. Transesophageal echocardiogram was negative for valvular clot as was electroencephalography and magnetic resonance imaging (MRI) of the brain. The patient's neurologist remained suspicious of embolic shower/small vessel disease precipitating these symptoms and advised the patient that he would likely experience complete recovery in weeks to months. Five months after the onset of symptoms, the patient sought a second opinion with another neurologist. After reviewing the old MRI images and agreeing there did not seem to be evidence of a stroke at that time, the second neurologist ordered a new repeat MRI of the patient's brain. The new MRI revealed eight microemboli in T2 and fluid-attenuated inversion recovery sequences [Figure 1] and [Figure 2]. At this time, the patient was taking aspirin and clopidogrel but continued to experience daily headaches, difficulty with concentration and decision-making, memory deficits, and easy fatigability.
|Figure 1: Magnetic resonance imaging head (T2 sequence) showing microemboli in the brain|
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|Figure 2: Magnetic resonance imaging head (fluid-attenuated inversion recovery sequence) showing microemboli in the brain|
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| Discussion|| |
PRP therapy has demonstrated beneficial effects in multiple disciplines that include surgical, orthopedic, wound care, dermatologic, and rehabilitation. High-level evidence supports its use in the treatment of lateral elbow extensor tendinopathy,,, but minimal data exist on postprocedural complications from PRP administration. We do not believe the injectate induced a hypercoagulable state, as there is no evidence to suggest localized PRP injection can create systemic coagulopathic effects. However, the preprocedural cessation of aspirin may have allowed the patient's prior prothrombotic risk factors to reemerge. There is ample evidence in the literature that demonstrate higher odds ratio for thromboembolic events upon cessation of antiplatelet agents.
The mechanism of action of aspirin involves the inhibition of platelet aggregation, which is a necessary prerequisite for the release of growth factors suspected to be the mechanism by which PRP therapy provides benefit. However, some literature indicate antiplatelets may not affect PRP growth factor profile. Thus, there is ongoing speculation and investigation into the effects of aspirin on PRP therapy. As with this case, many clinicians recommend cessation of aspirin 1 week before and 3 weeks after PRP therapy, yet there still remains a gap in clinical literature to support clear guidelines for optimizing PRP administration in the setting of anticoagulation, particularly aspirin. This case report highlights a high level of risk associated with stopping aspirin therapy when administering autologous PRP. This is a critical issue given that a high percentage of tendinopathies and primary osteoarthritis exist in a demographic that often require antiplatelet therapies. Formal guidelines and more clinically robust studies would elucidate the optimal timing of PRP in these settings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bertrand ME. When and how to discontinue antiplatelet therapy. Eur Heart J Suppl 2008;10:A35-41.
Schippinger G, Prüller F, Divjak M, Mahla E, Fankhauser F, Rackemann S, et al.
Autologous platelet-rich plasma preparations: Influence of nonsteroidal anti-inflammatory drugs on platelet function. Orthop J Sports Med 2015;3:2325967115588896.
Jayaram P, Yeh P, Patel SJ, Cela R, Shybut TB, Grol MW, et al.
Effects of aspirin on growth factor release from freshly isolated leukocyte-rich platelet-rich plasma in healthy men: A prospective fixed-sequence controlled laboratory study. Am J Sports Med 2019;47:1223-9.
Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006;34:1774-8.
Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al.
Efficacy of platelet-rich plasma for chronic tennis elbow: A double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med 2014;42:463-71.
Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: A double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med 2011;39:1200-8.
Maulaz AB, Bezerra DC, Michel P, Bogousslavsky J. Effect of discontinuing aspirin therapy on the risk of brain ischemic stroke. Arch Neurol 2005;62:1217-20.
Ludwig HC, Birdwhistell KE, Brainard BM, Franklin SP. Use of a cyclooxygenase-2 inhibitor does not inhibit platelet activation or growth factor release from platelet-rich plasma. Am J Sports Med 2017;45:3351-7.
Di Matteo B, Filardo G, Lo Presti M, Kon E, Marcacci M. Chronic anti-platelet therapy: A contraindication for platelet-rich plasma intra-articular injections? Eur Rev Med Pharmacol Sci 2014;18:55-9.
Cianca JC, Jayaram P. Musculoskeletal injuries and regenerative medicine in the elderly patient. Phys Med Rehabil Clin N Am 2017;28:777-94.
[Figure 1], [Figure 2]