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

Abstract

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.

Which traumatic brain injury patients should be treated with anticoagulants and when?

“…ICH progression in the cohort with routine chemoprophylaxis was 0.78%, which was essentially no different than in the cohort without chemoprophylaxis (2.8%). Of note, in our study, all patients had head Abbreviated Injury score >3, all patients had a follow-up head CT 48-72 h after initiation of chemoprophylaxis and chemoprophylaxis was intended to be initiated after a stable head CT 24 h after injury [4]. These results are consistent with those of Cothren et al [11], Dudley et al [12], Saadeh et al [13] and Thorson et al [14].…”

“…We are not aware of any studies focused on this particular issue, but given the negative impact of coagulopathy on TBI outcome, common sense dictates that chemoprophylaxis should be deferred until coagulopathy has been corrected and not recurred. Consistent with this view, a number of protocols have included coagulopathy as an exclusion criterion for chemoprophylaxis [4,9,10].…”

“…Significant systemic morbidity and mortality may occur with either prothrombotic or coagulopathic states including DVT, PE, myocardial infarction, ischemic stroke and systemic hemorrhage. Nevertheless, based upon a review of available literature and our own research [4], we favor chemoprophylactic anticoagulation in the treatment of TBI patients who have a stable 24-h post-injury head computed tomography (CT).…”

Unfractionated heparin after TBI reduces in vivo cerebrovascular inflammation, brain edema and accelerates cognitive recovery

“…11 Heparins have been used to reduce VTE risk in brain injured patients. 28,29 Heparin is a highly sulfated glycosaminoglycan most commonly stored in the secretory granules of mast cells. 12 Intriguingly and irrespective of its anticoagulant properties, other effects of heparin have recently been revealed, most notably their ability to reduce inflammation after injury.…”

The Risk of Postoperative Hemorrhage and Efficacy of Heparin for Preventing Deep Vein Thrombosis and Pulmonary Embolism in Adult Patients Undergoing Neurosurgery: A Systematic Review and Meta-Analysis

“…The observed effect can be explained by the fact that Farooqui et al 24 24 and Bauman et al 2 2 studies had higher relative weight (larger sample size), and their lower and upper limits were closer to CI than other studies. Subgroup analysis for association of UFH treatment with the rates of DVTs, PE and VTEs was not performed due to limited study numbers.…”