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

Clinical article

Restricted access

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.

Abbreviations used in this paper:AIS = Abbreviated Injury Scale; DVT = deep vein thrombosis; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage; ISS = Injury Severity Score; LOS = length of stay; PE = pulmonary embolism; TBI = traumatic brain injury; VTE = venous thromboembolism.

Article Information

Address correspondence to: N. Scott Litofsky, M.D., Division of Neurological Surgery, University of Missouri-Columbia School of Medicine, One Hospital Dr., MC 321, Columbia, MO 65212. email: litofskyn@health.missouri.edu.

Please include this information when citing this paper: published online September 20, 2013; DOI: 10.3171/2013.8.JNS13424.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    University of Missouri TBI DVT prophylaxis protocol. aPTT WNL = activated partial thromboplastin time within normal limits; INR = international normalized ratio; plts = platelets; PT = prothrombin time; SCD = sequential compression device.

  • View in gallery

    A and B: CT scans obtained in a patient with a subarachnoid hemorrhage (large arrow), contusion (small arrow), and punctuate hemorrhage (open arrow). C and D: CT scans obtained 24 hours after admission with progression of contusion (small arrow) and punctate hemorrhage (open arrow), delaying initiation of chemoprophylaxis.

References

1

Barmparas GSinger MLey EChung RMalinoski DMargulies D: Decreased intracranial pressure monitor use at level II trauma centers is associated with increased mortality. Am Surg 78:116611712012

2

Cage TALamborn KRWare MLFrankfurt AChakalian LBerger MS: Adjuvant enoxaparin therapy may decrease the incidence of postoperative thrombotic events though does not increase the incidence of postoperative intracranial hemorrhage in patients with meningiomas. J Neurooncol 93:1511562009

3

Chibbaro STacconi L: Safety of deep venous thrombosis prophylaxis with low-molecular-weight heparin in brain surgery. Prospective study on 746 patients. Surg Neurol 70:1171212008

4

Collen JFJackson JLShorr AFMoores LK: Prevention of venous thromboembolism in neurosurgery: a metaanalysis. Chest 134:2372492008

5

Cothren CCSmith WRMoore EEMorgan SJ: Utility of once-daily dose of low-molecular-weight heparin to prevent venous thromboembolism in multisystem trauma patients. World J Surg 31:981042007

6

Depew AJHu CKNguyen ACDriessen N: Thromboembolic prophylaxis in blunt traumatic intracranial hemorrhage: a retrospective review. Am Surg 74:9069112008

7

Dudley RRAziz IBonnici ASaluja RSLamoureux JKalmovitch B: Early venous thromboembolic event prophylaxis in traumatic brain injury with low-molecular-weight heparin: risks and benefits. J Neurotrauma 27:216521722010

8

Farahvar AGerber LMChiu YLCarney NHärtl RGhajar J: Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring. Clinical article. J Neurosurg 117:7297342012

9

Khaldi AHelo NSchneck MJOrigitano TC: Venous thromboembolism: deep venous thrombosis and pulmonary embolism in a neurosurgical population. Clinical article. J Neurosurg 114:40462011

10

Kim JGearhart MMZurick AZuccarello MJames LLuchette FA: Preliminary report on the safety of heparin for deep venous thrombosis prophylaxis after severe head injury. J Trauma 53:38432002

11

Kurtoglu MYanar HBilsel YGuloglu RKizilirmak SBuyukkurt D: Venous thromboembolism prophylaxis after head and spinal trauma: intermittent pneumatic compression devices versus low molecular weight heparin. World J Surg 28:8078112004

12

Kwiatt MEPatel MSRoss SELachant MTMacNew HGOchsner MG: Is low-molecular-weight heparin safe for venous thromboembolism prophylaxis in patients with traumatic brain injury? A Western Trauma Association multicenter study. J Trauma Acute Care Surg 73:6256282012

13

Minshall CTEriksson EALeon SMDoben ARMcKinzie BPFakhry SM: Safety and efficacy of heparin or enoxaparin prophylaxis in blunt trauma patients with a head abbreviated injury severity score >2. J Trauma 71:3964002011

14

Mohseni STalving PLam LChan LSIves CDemetriades D: Venous thromboembolic events in isolated severe traumatic brain injury. J Emerg Trauma Shock 5:11152012

15

Norwood SHBerne JDRowe SAVillarreal DHLedlie JT: Early venous thromboembolism prophylaxis with enoxaparin in patients with blunt traumatic brain injury. J Trauma 65:102110272008

16

Norwood SHMcAuley CEBerne JDVallina VLKerns DBGrahm TW: Prospective evaluation of the safety of enoxaparin prophylaxis for venous thromboembolism in patients with intracranial hemorrhagic injuries. Arch Surg 137:6967022002

17

Nurmohamed MTvan Riel AMHenkens CMKoopman MMQue GTd'Azemar P: Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery. Thromb Haemost 75:2332381996

18

O'Carroll CBCapampangan DJAguilar MIBravo TPHoffman-Snyder CRWingerchuk DM: What is the effect of low-molecular weight heparin for venous thromboembolism prophylaxis compared with mechanical methods, on the occurrence of hemorrhagic and venous thromboembolic complications in patients with intracerebral hemorrhage? A critically appraised topic. Neurologist 17:2322352011

19

Rayan NBarnes SFleming NKudyakov RBallard DGentilello LM: Barriers to compliance with evidence-based care in trauma. J Trauma Acute Care Surg 72:5855932012

20

Reiff DAHaricharan RNBullington NMGriffin RLMcGwin G JrRue LW III: Traumatic brain injury is associated with the development of deep vein thrombosis independent of pharmacological prophylaxis. J Trauma 66:143614402009

21

Saadeh YGohil KBill CSmith CMorrison CMosher B: Chemical venous thromboembolic prophylaxis is safe and effective for patients with traumatic brain injury when started 24 hours after the absence of hemorrhage progression on head CT. J Trauma Acute Care Surg 73:4264302012

22

Scudday TBrasel KWebb TCodner PSomberg LWeigelt J: Safety and efficacy of prophylactic anticoagulation in patients with traumatic brain injury. J Am Coll Surg 213:1481542011

23

Thorson CMRyan MLVan Haren RMCuria EBarrera JMGuarch GA: Venous thromboembolism after trauma: a never event?. Crit Care Med 40:296729732012

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 169 169 60
Full Text Views 281 281 13
PDF Downloads 155 155 9
EPUB Downloads 0 0 0

PubMed

Google Scholar