Prospective Evaluation of the Safety of Enoxaparin Prophylaxis for Venous Thromboembolism in Patients With Intracranial Hemorrhagic Injuries

Norwood, Scott H.; McAuley, Clyde E.; Berne, John D.; Vallina, Van L.; Kerns, D.Brent; Grahm, Thomas W.; Short, Kevin R.; McLarty, Jerry

doi:10.1001/archsurg.137.6.696

Cited by 141 publications

(93 citation statements)

References 21 publications

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“…18 Alternatively, enoxaparin has also been used in a selective postoperative neurosurgical patient population within 48 hours after surgery, decreasing incidence of DVTs from 4.8% to 0% with no associated increase in ICH. 2,9,11,16,20 Other studies have shown some efficacy of chemoprophylaxis in selected trauma patients with head injury. 1,14,15,21,22 Based on these studies, our trauma center adopted a new clinical protocol to initiate VTE chemoprophylaxis 24 hours following injury after demonstration of stable ICH verified by CT scan.…”

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confidence: 99%

Safety and efficacy of early thromboembolism chemoprophylaxis after intracranial hemorrhage from traumatic brain injury

Farooqui

Hiser

Barnes

et al. 2013

JNS

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Object Patients with traumatic brain injury (TBI) are at risk for development of thromboembolic disease. The use of chemoprophylaxis in this patient group has not fully been characterized. The authors hypothesize that early chemoprophylaxis in patients with TBI is safe and efficacious. Methods In May 2009, a protocol was instituted for patients with TBI where chemoprophylaxis for thromboembolic disease (either 30 mg of Lovenox twice daily or 5000 U of heparin 3 times a day) was initiated 24 hours after an intracranial hemorrhage (ICH) was demonstrated as stable on head CT image. Two cohorts were evaluated: Cohort A included patients from May 2008 through April 2009 who had no routine administration of chemoprophylaxis, and Cohort B included patients from May 2009 through May 2010 after the protocol was instituted. The groups were compared, with the major outcomes being deep venous thrombosis (DVT), pulmonary embolism, and increase in size of ICH. Results Of the 312 patients with TBI who were seen during the study course, 236 patients met criteria for inclusion in the study: 107 patients in Cohort A and 129 patients in Cohort B. The DVT rate was 6 occurrences (5.61%) in Cohort A and 0 occurrences (0%) in Cohort B, which was a statistically significant difference (p = 0.0080). Pulmonary embolism was found in 4 patients (3.74%) in Cohort A and 1 patient (0.78%) in Cohort B, a difference that did not reach statistical significance (p = 0.18). Three instances (2.8%) in Cohort A and 1 instance (0.7%) in Cohort B of increased ICH occurred after starting anticoagulation for chemoprophylaxis; this was not statistically different (p = 0.33). Conclusions Use of chemoprophylaxis in TBI 24 hours after stable head CT is safe and decreases the rate of DVT formation.

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confidence: 99%

Safety and efficacy of early thromboembolism chemoprophylaxis after intracranial hemorrhage from traumatic brain injury

Farooqui

Hiser

Barnes

et al. 2013

JNS

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“…[9][10][11][12][13][14][15][16][17][18] An exception to this general rule was the work of Berne and Norwood, who had promulgated a set of intracranial injury patterns that could safely receive enoxaparin 30 mg subcutaneously beginning 24 h after injury if a repeat CT scan of the head was stable. [6][7][8] Using their work as a starting point, our group modified these criteria and created the Parkland Protocol. This original version of the protocol …”

Section: Discussionmentioning

confidence: 99%

The Parkland Protocol's Modified Berne-Norwood Criteria Predict Two Tiers of Risk for Traumatic Brain Injury Progression

Pastorek

Cripps

Bernstein

et al. 2014

Journal of Neurotrauma

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As a basis for venous thromboembolism (VTE) prophylaxis after traumatic brain injury (TBI), we have previously published an algorithm known as the Parkland Protocol. Patients are classified by risk for spontaneous progression of hemorrhage with chemoprophylaxis regimens tailored to each tier. We sought to validate this schema. In our algorithm, patients with any of the following are classified ''low risk'' for spontaneous progression: subdural hemorrhage £ 8 mm thick; epidural hemorrhage £ 8 mm thick; contusions £ 20 mm in diameter; a single contusion per lobe; any amount of subarachnoid hemorrhage; or any amount of intraventricular hemorrhage. Patients with any injury exceeding these are ''moderate risk'' for progression, and any patient receiving a monitor or craniotomy is ''high risk.'' From February 2010 to November 2012, TBI patients were entered into a dedicated database tracking injury types and sizes, risk category at presentation, and progression on subsequent computed tomgraphies (CTs). The cohort (n = 414) was classified as low risk (n = 200), moderate risk (n = 75), or high risk (n = 139) after first CT. After repeat CT scan, radiographic progression was noted in 27% of low-risk, 53% of moderate-risk, and 58% of high-risk subjects. Omnibus analysis of variance test for differences in progression rates was highly significant ( p < 0.0001). Tukey's post-hoc test showed the low-risk progression rate to be significantly different than both the moderate-and high-risk arms; no difference was noted between the moderate-and high-risk arms themselves. These criteria are a valid tool for classifying TBI patients into two categories of risk for spontaneous progression. This supports tailored chemoprophylaxis regimens for each arm.

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“…These investigations also suggested that this prophylaxis protocol should be administered after 24 hour from all initial and subsequent craniotomies. However, it is well known that preoperative usage of anticoagulants could increase the risk of the intra-cerebral hemorrhage related to the surgery 5,16) . Our patient's frontal skin edema and periorbital edema made us to suspect from the dural venous sinus thrombosis especially cavernous sinus thrombosis; and to avoid from severe complications of this (such as hemiparesis, blindness, debility, etc.)…”

Section: Discussionmentioning

confidence: 99%

Bilateral Chronic Subdural Hematoma Contaminated with Klebsiella Pneumoniae : An Unusual Case

Bakar¹,

Sungur

Tekkök

2009

J Korean Neurosurg Soc

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J Korean Neurosurg Soc 45 : [397][398][399][400] 2009 This article presents the case of a bilateral chronic subdural hematoma which was contaminated with Klebsiella pneumoniae and resulted in a life-threatening central nervous system infection. After repeated of bilateral burr-hole drainage, the patient became hyperpyrexic and drowsy. Suppuration within the subdural space was suspected and then the patient underwent bilateral fronto-temporo-parietal craniotomies, and pus was evacuated. Its cultures revealed Klebsiella pneumoniae. Intravenous meropenem was given for 6 weeks. He recovered completely. Microorganisms like Klebsiella pneumoniae may directly infect the subdural space with iatrogenic contamination.

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Prospective Evaluation of the Safety of Enoxaparin Prophylaxis for Venous Thromboembolism in Patients With Intracranial Hemorrhagic Injuries

Cited by 141 publications

References 21 publications

Safety and efficacy of early thromboembolism chemoprophylaxis after intracranial hemorrhage from traumatic brain injury

Safety and efficacy of early thromboembolism chemoprophylaxis after intracranial hemorrhage from traumatic brain injury

The Parkland Protocol's Modified Berne-Norwood Criteria Predict Two Tiers of Risk for Traumatic Brain Injury Progression

Bilateral Chronic Subdural Hematoma Contaminated with Klebsiella Pneumoniae : An Unusual Case

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