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We read with great interest the recent paper by Wiegele et al. who describe treatment options in the case of traumatic brain injury (TBI), especially haemorrhagic TBI, in patients receiving oral anticoagulant therapy [1]. We would like to expand somewhat on the therapeutic options they described, in particular regarding ticagrelor and new oral anticoagulants (NOACs). For ticagrelor, a new therapeutic option may be the use of the CytoSorb device. Indeed, CytoSorb can efficiently remove anti-platelet agents in order to restore normal platelet function and to stop bleeding wherever it is occurring [2]. In their study, Angheloiu et al. were able to remove 99% of ticagrelor from human blood in less than 4 h when using CytoSorb [2]. The specific monoclonal antibody reversal agent for ticagrelor is not yet available at the bedside [3]. In the future, both therapies could be used to complement each other. For reversal of NOACs, CytoSorb may represent an effective, accessible and easy to use alternative to antidotes, which are often very expensive and not always available. In an experimental work by Koertge et al., it was found that more than 91% of rivaroxaban could be removed from the blood during 1 h use of CytoSorb [4]. This new therapy could perhaps complement the use of the antidote andexanet alfa, particularly if the antidote is not immediately available. In conclusion, we believe that studies comparing the two strategies (sorbents versus monoclonal antibodies) are urgently needed and that the use of CytoSorb to remove NOACs and antiplatelet agents in order to restore normal coagulation and to stop bleeding would be a very useful addition to the information presented in the Austrian recommendations.

critical care

Austrian recommendations for best clinical practice in case of haemorrhagic traumatic brain injury under platelet inhibitors or non-vitamin K antagonist oral anticoagulants: an additional therapeutic option to consider