Early thrombosis prophylaxis with enoxaparin is not associated with hematoma expansion in patients with spontaneous intracerebral hemorrhage

Abstract

Background and purpose Early pharmacological deep vein thrombosis (DVT) prophylaxis is recommended by guidelines, but rarely started within 48 h. We aimed to analyze the effect of early (within 48 h) versus late (>48 h) DVT prophylaxis on hematoma expansion (HE) and outcome in patients with spontaneous intracerebral hemorrhage (ICH). Methods We analyzed 134 consecutive patients admitted to a tertiary neurointensive care unit with diagnosed spontaneous ICH, without previous anticoagulation, severe coagulopathy, hematoma evacuation, early withdrawal of therapy or ineligibility for DVT prophylaxis according to our institutional protocol. Significant late HE was defined as ≥6 mL increase of hematoma volume between neuroimaging within 48 h and day 3–6. Multivariate analysis was performed to identify risk factors for late HE, poor 3‐month outcome (modified Rankin Scale score ≥ 4) and mortality. Results Patients had a median Glasgow Coma Scale score of 14 [interquartile range (IQR), 10–15], ICH volume of 11 (IQR, 5–24) mL and were 71 (IQR, 61–76) years old. A total of 56% (n = 76) received early DVT prophylaxis, 37% (n = 50) received late DVT prophylaxis and 8 (6%) had unknown bleeding onset. Patients with early DVT prophylaxis had smaller ICH volume [9.5 (IQR, 4–18.5) vs. 17.5 (IQR, 8–29) mL, P = 0.038] and were more often comatose (26% vs. 10%, P = 0.025). Significant late HE [n = 5/134 (3.7%)] was associated with larger initial ICH volume (P = 0.02) and lower thrombocyte count (P = 0.03) but not with early DVT prophylaxis (P = 0.36). Early DVT prophylaxis was not associated with worse outcome. Conclusion Significant late HE is uncommon and DVT prophylaxis within 48 h of symptom onset may be safe in selected patients with ICH.

PREvention of VENous Thromboembolism in Hemorrhagic Stroke Patients – PREVENTIHS Study: A Randomized Controlled Trial and a Systematic Review and Meta-Analysis

“…After scanning titles and abstracts, 444 citations were excluded and 21 were retained for further evaluation. From these, 11 studies were excluded for the following reasons: 9 studies did not have a control group [3-21]; one study used vitamin K antagonists [22]; and in one study treatment was given during rehabilitation after 7 days from stroke onset [23]. One further randomized study [24] was excluded because the results of this trial had been included in the results of the study reported by Boeer et al [25].…”

Prognostic Nomogram for Predicting Lower Extremity Deep Venous Thrombosis in Neurointensive Care Unit Patients: A Prospective Observational Study

“…This study has certain clinical significance for neurointensive care unit medical staff and patients: early administration of anticoagulants remains a controversial issue, as some researchers have indicated that early pharmacological prophylaxis increases the risk of bleeding (20,21), whereas others argued that early use of anticoagulants is not associated with late bleeding (22,23); furthermore, there are no clear guidelines for the application of anticoagulants in neurointensive care unit patients with different diagnoses; however, the prognostic nomogram model may assist neurosurgeons in the early identification of high-risk patients to provide them with active individual anticoagulant treatment after cautious assessment of thrombosis vs. bleeding.…”

Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020

“…46 These results are supported by a prospective observational study demonstrating the absence of hematoma expansion with LMWH started within 48 h of ICH onset after hematoma stabilization compared to later initiation in 134 consecutive patients. 47 Similarly, in another observational study of 407 ICH patients, there was no increase in ICH expansion between those treated with LMWH (85% started within 48 h) or those receiving no chemoprophylaxis. 48 Following ICH, patients are at increased risk of seizures.…”