Low-dose intravenous heparin infusion in patients with aneurysmal subarachnoid hemorrhage: a preliminary assessment

Clinical article

J. Marc Simard M.D., Ph.D. 1 , 2 , 3 , E. Francois Aldrich M.B., Ch.B., M.Med., F.C.S. 1 , David Schreibman M.D. 1 , 4 , Robert F. James M.D. 1 , Adam Polifka M.D. 1 , and Narlin Beaty M.D. 1
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  • 1 Departments of Neurosurgery,
  • 2 Pathology,
  • 3 Physiology, and
  • 4 Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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Object

Aneurysmal subarachnoid hemorrhage (aSAH) predisposes to delayed neurological deficits, including stroke and cognitive and neuropsychological abnormalities. Heparin is a pleiotropic drug that antagonizes many of the pathophysiological mechanisms implicated in secondary brain injury after aSAH.

Methods

The authors performed a retrospective analysis in 86 consecutive patients with Fisher Grade 3 aSAH due to rupture of a supratentorial aneurysm who presented within 36 hours and were treated by surgical clipping within 48 hours of their ictus. Forty-three patients were managed postoperatively with a low-dose intravenous heparin infusion (Maryland low-dose intravenous heparin infusion protocol: 8 U/kg/hr progressing over 36 hours to 10 U/kg/hr) beginning 12 hours after surgery and continuing until Day 14 after the ictus. Forty-three control patients received conventional subcutaneous heparin twice daily as deep vein thrombosis prophylaxis.

Results

Patients in the 2 groups were balanced in terms of baseline characteristics. In the heparin group, activated partial thromboplastin times were normal to mildly elevated; no clinically significant hemorrhages or instances of heparin-induced thrombocytopenia or deep vein thrombosis were encountered. In the control group, the incidence of clinical vasospasm requiring rescue therapy (induced hypertension, selective intraarterial verapamil, and angioplasty) was 20 (47%) of 43 patients, and 9 (21%) of 43 patients experienced a delayed infarct on CT scanning. In the heparin group, the incidence of clinical vasospasm requiring rescue therapy was 9% (4 of 43, p = 0.0002), and no patient suffered a delayed infarct (p = 0.003).

Conclusions

In patients with Fisher Grade 3 aSAH whose aneurysm is secured, postprocedure use of a low-dose intravenous heparin infusion may be safe and beneficial.

Abbreviations used in this paper:aPTT = activated partial thromboplastin time; aSAH = aneurysmal subarachnoid hemorrhage; CTA = CT angiography; DND = delayed neurological deficit; DSA = digital subtraction angiography; DVT = deep vein thrombosis; GCS = Glasgow Coma Scale; HIT = heparin-induced thrombocytopenia; MCA = middle cerebral artery; WFNS = World Federation of Neurosurgical Societies.

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Contributor Notes

Current affiliation for Dr. James: East Carolina University Brody School of Medicine, ECU Neurosurgical and Spine Center, Greenville, NC.

Address correspondence to: J. Marc Simard, M.D., Ph.D., Department of Neurosurgery, 22 S. Greene St., Ste. S12D, Baltimore, MD 21201. email: msimard@smail.umaryland.edu.

Please include this information when citing this paper: published online September 13, 2013; DOI: 10.3171/2013.8.JNS1337.

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