Abstract
This is a really excellent case for discussion. Mild hypothermia is associated with impaired coagulation tests in laboratory conditions, including platelet activity2,3.
Body temperature may thus have contributed to the intracranial bleeding in the setting of very intensive antiplatelet therapy and may also explain the coincidence of the "rewarming" phase and stent thrombosis. As far as the episode of stent thrombosis is concerned, I would also have selected unfractionated heparin, but the dose used (100 IU/kg) seems to be relatively high.
I agree that the risk of adding a glycoprotein IIb/IIIa inhibitor is excessive. There is evidence that the efficacy of oral clopidogrel medication is lower in critically ill patients4.
Ticagrelor might have a theoretical advantage over clopidogrel from a pharmacological perspective; however, any clinical relevance in this setting is not known.