Neurocrit Care (2022) 36:164–170

https://doi.org/10.1007/s12028-021-01277-2

ORIGINAL WORK

Desmopressin Administration and Impact

on Hypertonic Saline Effectiveness
in Intracranial Hemorrhage
Emily Bowers1* , Eric Shaw2,3, William Bromberg4 and Audrey Johnson1

© 2021 Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society

Abstract
Introduction: Desmopressin improves hemostasis through the release of factor VIII, von Willebrand factor, and tis-
sue plasminogen activator, and increases platelet adhesion. Neurocritical Care guidelines recommend consideration
of desmopressin in antiplatelet-associated intracranial hemorrhage. Studies supporting its use have not evaluated
the potential impact of desmopressin on serum sodium levels in patients receiving hypertonic saline therapy. The
purpose of this study was to assess the impact of desmopressin on sodium levels and hypertonic saline effectiveness
in intracranial hemorrhage.
Methods: This was a single center retrospective observational chart review. Patients were included in the desmo-
pressin group if they were diagnosed with intracranial hemorrhage, administered desmopressin, and received
hypertonic saline infusion. Patients in the hypertonic saline alone group were then matched 1:1 to the patients
in the desmopressin group. The primary end point was the effect of desmopressin on reaching a sodium goal of
145–155 mEq/L. The secondary end points included intensive care unit and hospital length of stay, change in sodium,
time to reach sodium goal, thrombotic events, mortality, and a composite of increased cerebral edema, hematoma
expansion, midline shift, herniation, need for neurosurgical intervention, and neurologic decompensation.
Results: Of 112 patients screened, 25 patients met inclusion criteria for the desmopressin group, and 25 patients
were matched with patients in the hypertonic saline alone group. The percentage of patients who reached goal
sodium in the desmopressin group compared with hypertonic saline alone was similar (80% vs. 88%, respectively).
There were no differences in the secondary end points. In the subgroup analysis, patients in the hypertonic saline
group met the predefined sodium goal of 150–155 mEq/L within 48 h more often than those in the desmopressin
group (82% vs. 60%, respectively, p = 0.042).
Conclusions: The use of desmopressin in intracranial hemorrhage does not appear to negatively impact the ability
for patients to reach goal sodium of 145–155 mEq/L. However, in patients with higher sodium goals, desmopressin
may decrease hypertonic saline effectiveness.
Keywords: Intracranial hemorrhage, Antiplatelet, Aspirin, Desmopressin, Hypertonic saline

*Correspondence: Emily.bowers@hcahealthcare.com
1
Department of Pharmacy, Memorial Health University Medical Center,
4700 Waters Avenue, Savannah, GA 31404, USA
Full list of author information is available at the end of the article
Introduction
Intracranial hemorrhage (ICH) is a cerebrovascular
condition associated with a number of adverse neuro-
logic events that lead to long-term morbidity and mor-
tality. The management strategies used to treat ICH are
directed toward reducing these adverse events by mini-
mizing hematoma expansion and limiting cerebral edema

[1, 2]. Antiplatelet and other antithrombotic therapies
are major contributors to hematoma expansion during
ICH and are associated with poor functional outcomes
and increased mortality. Efforts to reverse these agents
and other bleeding disorders contributing to hematoma
expansion remain an important component of initial
therapy [3–5].
Desmopressin (DDAVP) is a synthetic analog of vaso-
pressin that improves hemostasis through the release of
factor VIII, von Willebrand factor, and tissue plasmino-
gen activator as well as increases platelet adhesion [6].
DDAVP has historically been used to promote hemosta-
sis in multiple bleeding disorders, including von Wille-
brand, uremic bleeding, and thrombocytopenia [7–9].
More recently, the use of DDAVP has also extended to
ICH associated with antiplatelet use [10]. The 2016 Neu-
rocritical Care guidelines for “Reversal of Antithrom-
botics in Intracranial Hemorrhage” recommend the
consideration of a single dose of desmopressin 0.4 μg/kg
in ICH associated with aspirin, adenosine diphosphate
receptor inhibitors, ­P2Y12 inhibitors, and uremia to limit
hematoma expansion [11].
The management of intracranial pressure (ICP) and
cerebral edema is also a mainstay of therapy for ICH. This
is commonly achieved through the administration of a
hypertonic saline (HTS) infusion aimed at raising sodium
levels to 145–155 mEq/L [12]. HTS provides decreases
in ICP and cerebral edema by causing an osmotic gradi-
ent. DDAVP, in addition to its ability to cause hemosta-
sis, binds to the ­V2 receptor in the collecting ducts of
the kidney, increases water reabsorption, and is com-
monly used to treat hypernatremia. The duration of anti-
diuretic action of DDAVP is approximately 12 h (with
much smaller doses than used for reversal) and has been
reported to last for up to 24 h [13]. Because of this mech-
anism of action, DDAVP can cause potential interactions
that diminish the effect of hypertonic saline when used in
conjunction for management of ICH. This could be detri-
mental to the neurologic outcomes in this patient popu-
lation [14].
Overall, there are limited data assessing the use of
desmopressin in ICH. Studies that support the use of
DDAVP for hemostasis in ICH did not evaluate hyper-
tonic saline use and change in serum sodium levels with
its administration [15–17]. The use of low dose DDAVP
and its effects on serum sodium in traumatic brain injury
was evaluated in a 2019 study by Harrois and colleagues
[18]. This study, however, focused on patients with
hypernatremia associated with diabetes insipidus. They
found that the use of DDAVP did not lead to a significant
decrease in sodium. To our knowledge, there have been
no studies published specifically evaluating high dose
DDAVP (0.4 μg/kg) used for reversal in ICH and impact
165
on serum sodium in patients receiving hypertonic saline
infusion therapy. The purpose of this study was to assess
the impact of desmopressin on serum sodium levels and
hypertonic saline infusion effectiveness in ICH.
Methods
Study Design, Setting, Data Sources, Participants, Variables
This study was a single center retrospective observational
chart review conducted at a 612-bed level I trauma, aca-
demic medical center. The study was approved by the
institutional review board. Data were collected through
the electronic medical record. Patients were identified
using International Classification of Diseases, Tenth
Revision codes for any ICH (including subarachnoid
hemorrhage, subdural hematoma, intraparenchymal
hemorrhage, and intraventricular hemorrhage) and
medication identification numbers for desmopres-
sin and hypertonic saline. All adult patients admitted
to MHUMC between July 1, 2015, through March 31,
2020, were screened for inclusion. Patients were eligible
for inclusion into the desmopressin plus 3% hypertonic
saline infusion group if they were diagnosed with an ICH,
received desmopressin for antiplatelet reversal, and were
administered 3% hypertonic saline infusion within 12 h of
the DDAVP dose. Patients were excluded if they were less
than 18 years old, pregnant, incarcerated, hyponatremic
at baseline defined as a serum sodium < 130 mEq/L, brain
death was determined within 24 h, or if they received
oral/intranasal desmopressin. Patients in the hypertonic
saline infusion alone group were then matched in a 1:1
fashion to patients in the desmopressin plus hypertonic
saline infusion based on age, weight, and sex.
Primary End Point
The primary end point was reaching goal serum sodium
within 145–155 mEq/L, as predetermined by the medi-
cal team, in patients who received DDAVP, compared
with patients who did not receive DDAVP in ICH. Serum
sodium was trended every 6 h for a total of 48 h after the
dose of DDAVP was administered and the start of the
hypertonic saline infusion, as the initial 48 h are critical
for clinically significant cerebral edema. Patients were
considered to have met goal sodium if they reached the
specific predefined sodium goal set by the medical team.
Secondary End Points
The secondary end points of this study included a com-
posite of neurologic outcomes including any increase in
cerebral edema on imaging, worsening hematoma expan-
sion, midline shift, herniation, need for unplanned neu-
rosurgical intervention (defined as emergent ICP monitor
placement or emergent decompressive craniotomy), and
neurologic decompensation (defined as any decrease in
166
Glasgow Coma Score, need for intubation, or increase
in ICPs above 20 mm Hg). These end points were moni-
tored for a total of 5 days after the initial ICH. Addi-
tional secondary end points included intensive care unit
(ICU) length of stay, hospital length of stay, net change in
sodium within 48 h from desmopressin administration,
time to goal serum sodium range, thrombotic events, and
mortality. A predefined subgroup analysis was completed
for patients who had a goal sodium of 145–150 mEq/L or
150–155 mEq/L, as specified by the medical team. These
subgroups were investigated to evaluate if patients who
had higher sodium goals set by the medical team were
more impacted by DDAVP administration.
Statistics
Data were analyzed by the Memorial Health University
Medical Center research team and statistician using sta-
tistical software SPSS (Released 2016. IBM SPSS Statistics
for Windows, version 24.0; IBM Corporation, Armonk,
NY). Categorical variables were summarized using fre-
quencies and percentages, whereas descriptive statistics
for continuous variables included mean, median, stand-
ard deviation, and minimum and maximum values. For
the primary and secondary outcomes, comparative analy-
ses were performed using the t-test and Fischer’s exact
test as appropriate (depending on the type of variable
and normality of the data). All inferential statistical tests
were two-tailed and used a tolerance for nominal type 1
error (α) of 0.05. p values produced by descriptive statis-
tics for all measured variables were reported. Significance
was set at a p value less than 0.05. The sample size was a
convenience sample.
Results
Patient Demographics
There was a total of 112 patients screened, and 25 patients
were included in the desmopressin plus hypertonic saline
112 paents 87 paents met
screened exclusions criteria
Definions: DDAVP = desmopressin, HTS = hypertonic saline infusion, DI = diabetes insipidus,
ICH = intracranial hemorrhage
Fig. 1 Patient inclusion and exclusion. DDAVP, desmopressin, DI, diabetes insipidus, HTS, hypertonic saline infusion, ICH, intracranial hemorrhage
infusion (DDAVP + HTS) group. Twenty-five patients
were then matched to be included in the hypertonic
saline infusion alone (HTS) group (Fig. 1). Baseline char-
acteristics were similar between the two groups (Table 1).
The average age was 65 years, 80% of patients were men,
and baseline serum sodium were similar between the
groups. Type of ICH, location, and volume were similar
between the two groups. The average dose of DDAVP in
the DDAVP + HTS group was 31 μg (0.34 μg/kg), and the
average time to initiation of HTS infusion from DDAVP
administration was 4 h. There were no significant differ-
ences between the two groups regarding net fluid balance
over 48 h after desmopressin administration, as well as
normal saline and dextrose 5% in water use. HTS infu-
sion rates were similar between the two groups. The
mean HTS infusion rate in the DDAVP + HTS group was
37 mL/h (± 14), compared with the HTS alone group
at 47 mL/h (± 10), p = 0.13. Anticoagulant use was also
reported, and there were no major differences in use
between the two groups. All anticoagulants were appro-
priately reversed in our study population. The use of con-
comitant agents effecting sodium was also evaluated, and
there were no significant differences between the two
groups.
Primary and Secondary Outcomes
The primary outcome reaching goal sodium within
145–155 mEq/L was achieved in 80% of patients in the
DDAVP + HTS group, compared with 88% in the HTS
alone group (p = 0.7) (Table 2). The secondary outcomes
are displayed in Table 4. There were no major differ-
ences between the two groups in time to goal sodium,
net change in sodium, ICU length of stay, hospital length
of stay, thrombotic events, or mortality (Table 3). For
the composite outcome, there were no major differences
between the two groups (Table 4). When looking at the
individual components of the composite outcome, the
25 paents
included in DDAVP Exclusions
+ HTS group 50: DDAVP for DI not ICH
23: No HTS administered
8: HTS administered > 12
hrs from DDAVP dose
6: Brain death within 24
25 paents hours
matched in HTS
alone
 167

Table 1 Baseline demographics Table 3 Secondary outcomes

DDAVP + HTS HTS alone (n = 25) p value DDAVP + HTS HTS alone (n = 25) p value
(n = 25) (n = 25)

Age (year) 65 (10) 65 (11) 1 Time to goal Na (h) 19.7 (12) 17.5 (10) 0.52
Weight (kg) 88 (20) 91.7 (18) 0.5 Net change in Na 12 (6) 12 (5) 1
Male sex, n (%) 20 (80) 20 (80) 1 (mEq/L)
Baseline serum Na, 138 (3.2) 139 (4) 0.33 ICU (d) 8 (6) 10 (7) 0.28
(mEq/L) Hospital (d) 15 (12) 14 (9) 0.74
DDAVP (μg) 31 (9) – – Mortality 12 (48) 10 (44) 0.78
DDAVP (μg/kg) 0.34 (0.05) – – Thrombotic events 0 (0) 2 (8) 0.49
Net fluid balance (L) 4.5 (1.9) 4.1 (1.6) 0.42 All values presented as n%
HTS infusion (mL/h) 37 (14) 43 (10) 0.13 There were no major differences between the two groups in time to goal
HTS boluses 4 (3) 5 (3) 0.24 sodium, net change in sodium, ICU length of stay, hospital length of stay,
mortality, or thrombotic events
Baseline GCS 10 (4.3) 10 (4.1) 1
DDAVP desmopressin, HTS hypertonic saline infusion, ICU intensive care unit, Na
Na goal, n (%) (mEq/L) sodium
145–155 10 (40) 5 (20) 0.22
145–150 5 (20) 3 (12) 0.70
150–155 10 (40) 17 (68) 0.09 need for neurosurgical intervention was lower in the
Anticoagulant use, n (%) HTS alone group at 10% of patients, compared with the
Rivaroxaban 1 (4) 2 (8) 1 DDAVP + HTS group at 33%; however, this was not sta-
Apixaban 1 (4) 1 (4) 1 tistically significant (p = 0.2). The net change in sodium
Warfarin 1 (4) 1 (4) 1 between the two groups is displayed in Fig. 2. Although
Type of ICH, n (%) not statistically significant, patients in the HTS alone
SAH 5 (20) 4 (16) 0.42 group were able to consistently maintain higher sodium
SDH 4 (16) 2 (8) 0.67 levels throughout the 48 h serum sodium was trended.
IPH 8 (32) 12 (48) 0.39
IVH 1 (4) 0 (0) 1
Subgroup Analysis
Combined 7 (28) 7 (28) 1
In the subgroup analysis of patients with a goal sodium
Concomitant medications effecting Na, n (%)
of 145–150 mEq/L, no difference was found in the abil-
0.9% sodium chloride 20 (80) 17 (70) 0.52
ity to meet the goal or net change in sodium between
Dextrose 5% in water 9 (40) 7 (30) 0.76
the two groups (Table 5). However, there was a trend
SSRIs 1 (4) 1 (4) 1
toward patients in the HTS alone group reaching their
Furosemide 2 (8) 3 (12) 1
sodium goal faster at 18 h, compared with 32 h in the
Thiazides 0 (0) 1 (4) 1
DDAVP + HTS group (p = 0.2).
All values presented as mean (± SD), unless otherwise noted In the subgroup analysis of patients with a goal sodium
DDAVP desmopressin, GSC Glasgow Coma Score, HTS hypertonic saline infusion, of 150–155 mEq/L, there was a significant difference
IPH intraparenchymal hemorrhage, IVH intraventricular hemorrhage ,
Na sodium, SAH subarachnoid hemorrhage, SD standard deviation, in patients who reached goal sodium in the HTS alone
SDH subdural hematoma, SSRIs selectiveserotoninreuptake inhibitors group at 82%, compared with the DDAVP + HTS group
at 60% (p = 0.042) (Table 6). No difference was found in
time to goal sodium or net change in sodium.

Discussion
Table 2 Primary outcome In this retrospective study, we aimed to evaluate the
impact of desmopressin administration on serum
DDAVP + HTS HTS alone (n = 25) p value
(n = 25) sodium levels and hypertonic saline infusion effective-
ness in ICH. Moreover, we aimed to assess this impact
Sodium 145–155 20 (80) 22 (88) 0.7 in relation to not only serum sodium levels but impor-
(mEq/L)
tant patient-centered clinical outcomes, including
All values presented as n (%)
neurologic deterioration and need for emergent inter-
The primary outcome of reaching a sodium of 145–155 mEq/mL was achieved in
88% of patients in the HTS alone group, compared with only 80% of patients in
ventions. We found that desmopressin administration
the DDAVP + HTS group did not significantly impact the ability for patients to
DDAVP desmopressin, HTS hypertonic saline infusion reach goal sodium of 145–155 mEq/L. However, there
168

Table 4 Composite secondary outcome

DDAVP + HTS (n = 25) HTS alone (n = 25) p value

Total, n (%) 18 (60) 20 (76) 0.74

Hematoma expansion 4 (26) 4 (21) 1
Cerebral edema 4 (26) 7 (36) 0.7
Midline shift 8 (32) 8 (32) 1
Herniation 2 (8) 2 (8) 1
Emergent neurosurgical intervention 5 (33) 2 (10) 0.2
  EVD 3 (20) 1 (5) 0.3
  Craniotomy 2 (13) 1 (5) 0.6
Neurologic decompensation 8 (53) 9 (47) 1
  Decreased GCS 5 (33) 7 (36) 0.8
  Increased ICP 3 (20) 2 (19) 0.6
All values presented as mean (± SD), unless otherwise noted
The composite of neurologic outcomes were defined as follows: any increase in cerebral edema on imaging, worsening hematoma expansion, midline shift,
herniation, need for emergent neurosurgical intervention (defined as emergent ICP monitor placement or emergent decompressive craniotomy), and neurologic
decompensation (defined as any decrease GCS, need for intubation, or increase in ICPs above 20 mm Hg)
There was a total of 18 patients in the DDAVP + HTS group that met the composite secondary outcome compared with 20 patients in the HTS alone group. When
looking at the individual components of the composite outcome, the need for neurosurgical intervention was lower in the HTS alone group at 10% of patients,
compared with the DDAVP + HTS group at 33%; however, this was not statistically significant (p = 0.2)
DDAVP desmopressin, EVD external ventricular drain, GCS Glasgow Coma Score, HTS hypertonic saline infusion, ICP intracranial pressure, SD standard deviation

165

160

155
Sodium, mEq/L

150 HTS alone

DDAVP + HTS

145

140

135
6 12 18 24 30 36 42 48
Time, hours
Fig. 2 Net change in serum sodium over time. The net change in sodium between the two groups is displayed in Fig. 2. Although not statisti-
cally significant, it is demonstrated that patients in the HTS alone group (dotted blue line) were able to consistently maintain higher sodium levels
throughout the 48 h serum sodium was trended. DDAVP, desmopressin, HTS, hypertonic saline infusion

was a trend toward greater need for neurosurgical a larger sample size is needed to appropriately address
intervention in the DDAVP + HTS group (10% vs. 33%, this comparison. It is also important to note there was a
p = 0.2). This result was not statistically significant, and trend toward patients in the HTS alone group reaching
 169

Table 5 Subgroup analysis for goal sodium 145– to treat patients at risk for herniation in the setting of
150 mEq/L ICH; however, this patient population has not been eval-
DDAVP + HTS HTS alone (n = 3) p value uated in the current available desmopressin studies.
(n = 5) In one particular study evaluating high dose DDAVP
(0.4 μg/kg) use in ICH associated with known aspirin
Met goal sodium 3 (60) 3 (100) 0.46
145–150, n (%) (mEq/L) use or reduced platelet activity, DDAVP improved meas-
Time to goal Na (h) 32 (12) 18 (14) 0.2 ures of platelet activity, increased von Willebrand factor,
Net change in Na (mEq/L) 8 (4.4) 8 (3.8) 1 and decreased hematoma volume. This study reported a
mean serum sodium change from baseline to follow-up
All values presented as mean (± SD), unless otherwise noted
at 12 to 24 h of 0.6 mEq/L; however, they did not assess
In the subgroup analysis of patients with a goal sodium of 145–150 mEq/L
(defined by medical team), no difference was found in the ability to meet goal this outcome in patients requiring HTS therapy [20]. In
or net change in sodium between the two groups. However, patients in the HTS contrast, our study sought out to establish this relation-
alone group did reach goal sodium faster at 18 h, compared with 32 h in the
DDAVP + HTS group ship and assess the impact of impeding HTS therapy.
DDAVP desmopressin, HTS hypertonic saline infusion, Na sodium, SD standard We found that the average change in serum sodium was
deviation 12 mEq/L in both groups, which is much higher than
the previous study mentioned but was expected because
patients were receiving HTS infusions. Although our
Table 6 Subgroup analysis for goal sodium 150– study did not find a significant difference in our primary
155 mEq/L outcome, we were able to find an association of DDAVP
DDAVP + HTS HTS alone (n = 17) p value hindering HTS therapy effectiveness in patients who had
(n = 10) higher sodium goals.
Met goal sodium 6 (60) 14 (82) 0.042 Another study published by Feldman and colleagues
150–155, n (%) (mEq/L) [19] examined high dose DDAVP (average dose 0.34 μg/
Time to goal Na (h) 28 (12) 23 (14) 0.33 kg) effectiveness and safety in antiplatelet-associated
Net change in Na 15 (2) 12 (5) 0.08 intracranial hemorrhage. The safety outcomes evaluated
(mEq/L) were the largest absolute decrease from baseline serum
All values presented as mean (± SD), unless otherwise noted sodium during the first 3 days of therapy and throm-
In the subgroup analysis of patients with a goal sodium of 150–155 mEq/L botic events. They found that DDAVP administration
(as defined by medical team), there was a significant difference in patients
who reached goal sodium in the HTS alone group at 82%, compared with the did not significantly affect serum sodium and throm-
DDAVP + HTS group at 60%. No difference was found in time to goal sodium or botic events, with the largest decrease in serum sodium
net change in sodium
being 0.0 mEq/L (interquartile range 0.0–5.0 mEq/L).
DDAVP desmopressin, HTS hypertonic saline infusion, Na sodium, SD standard
deviation
This study did report HTS use in 35.2% of patients who
received DDAVP [19]. Unlike our study, they did not
report HTS therapy goal sodium levels or assess DDAVP’s
goal sodium faster at 18 h, compared with 32 h in the direct impact on achieving higher sodium goals.
DDAVP + HTS group (p = 0.2). Even though this result Our findings imply that, overall, high dose DDAVP was
was not statistically significant, it is still clinically sig- safe to use with HTS infusions and did not affect reach-
nificant, as it could delay the benefit of HTS therapy. ing general sodium goals of 145–155 mEq/L. However,
Finally, in the subgroup analysis of patients with a in patients who receive DDAVP and require HTS ther-
higher sodium goal (150–155 mEq/L), there was a sig- apy with a higher sodium goal, clinicians could consider
nificant difference in patients who reached goal sodium increasing HTS infusion rates and decreasing adjunctive
in the HTS alone group at 82%, compared with the intravenous fluids.
DDAVP + HTS group at 60% (p = 0.042). This suggests Our study has several strengths. The study was the
that DDAVP administration does impact HTS therapy first to this date to look directly at desmopressin use for
effectiveness and the need for more aggressive meas- reversal in ICH and impact on HTS infusion therapy. It
ures to raise sodium in this specific patient population. assessed clinically relevant data on important outcomes,
DDAVP administration in ICH has been evaluated in such as hematoma expansion, cerebral edema, and neu-
several studies and is recommended to be considered rologic deterioration. Finally, the results do have clinical
for reversal in current guidelines [15–17, 19]. Although implications.
the use of DDAVP in this setting has been validated, the There were several limitations to this study. The study
effects on serum sodium has not been thoroughly evalu- design was retrospective in nature and there was a small
ated. HTS therapy to attain higher sodium levels is a sample size, which could limit the external validity and
mainstay of therapy for cerebral edema and is often used generalizability of the results. Though treatment arms
170
were matched by demographics and clinical presentation,
there was potential for selection bias because this method
may have failed to capture all clinical parameters that a
truly randomized allocation might. Concomitant fluid
administration could have interfered with HTS adminis-
tration and serum sodium levels, but this was attempted
to be controlled for by evaluating fluid administration
in both study groups. Additionally, only patients who
received a continuous infusion of HTS were evaluated in
our primary end point, and patients who received only
bolus HTS were excluded. Quantitative assessment of
hematoma expansion, midline shift, and cerebral edema
was not performed, which could limit the ability to evalu-
ate the clinical impact of the findings of this study. Lastly,
our patient population size was a convenience sample
with no power calculation.
Conclusions
In conclusion, DDAVP use in ICH does not appear to
negatively impact the ability for patients to reach goal
sodium of 145–155 mEq/L. However, in patients who
have higher sodium goals, DDAVP may decrease HTS
effectiveness. Further larger, randomized studies are
needed to assess the relevance of these results on clinical
outcomes.
Author details
1
Department of Pharmacy, Memorial Health University Medical Center, 4700
Waters Avenue, Savannah, GA 31404, USA. 2 Department of Clinical Trials,
Memorial Health University Medical Center, 4700 Waters Avenue, Savannah,
GA 31404, USA. 3 Mercer University School of Medicine, Savannah, Savannah,
GA, USA. 4 Department of Surgery, Memorial Health University Medical Center,
4700 Waters Avenue, Savannah, GA 31404, USA.
Author contributions
All authors made substantial contributions to the conception and design,
acquisition of data, or analysis and interpretation of data, drafting the article
and revising it critically for important intellectual content, and approve of the
final version to be published.
Source of support
No funding was received for this project. This research was supported (in
whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated
entity. The views expressed in this publication represent those of the author(s)
and do not necessarily represent the official views of HCA Healthcare or any of
its affiliated entities.
Conflicts of Interest
The authors have no conflicts of interest to disclose.
Ethical approval/informed consent
The study adhered to all ethical guidelines and due to its retrospective nature
did not require the use of informed consent. A statement of IRB approval is
provided as a supplemental material.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.
Received: 3 August 2020 Accepted: 11 May 2021
Published online: 7 July 2021
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