Advance Access: Early Venous Thromboembolism Chemoprophylaxis After Traumatic Intracranial Hemorrhage

Traumatic brain injury (TBI) results in significant morbidity and mortality. These patients often require extended hospitalization for close monitoring and treatment, especially when they sustain multisystem injuries. Often, cognitive or motor deficits contribute to prolonged immobilization. As a result, venous thromboembolic events (VTE) are common and potentially devastating complications in this cohort. Trauma patients have a reported incidence of VTE as high as 50%; in some studies, TBI itself is an independent risk factor for VTE with an estimated incidence of 25% when chemoprophylaxis is delayed or not administered.1,-4 This rate is significantly reduced when prophylactic anticoagulation is initiated within 72 h of admission.5 Nonetheless, practitioners are hesitant to initiate anticoagulant medications due to the potential risk of exacerbating intracranial hemorrhage.

The timing of initiating chemoprophylaxis is controversial and generally dependent on the individual physician or hospital and service practices. Single-center protocols have been published based upon clinical or radiographic criteria.6,7 Recently, a randomized, placebo-controlled clinical trial evaluated the safety of prophylactic anticoagulation 24 h after a low-risk TBI.8 All patients in the study had radiographically stable intracranial hemorrhage prior to onset of anticoagulation. It was found that the rate of radiographic progression after initiation of anticoagulation was similar to placebo. Furthermore, any progression was not clinically significant. Another retrospective study demonstrated that, when initiated within 24 h of stable serial imaging (48-72 h after initial presentation), the administration of unfractionated or low molecular weight heparin reduces the incidence of VTE to 0% to 4%.9 Moreover, the authors did not find an increased risk of expanded intracranial hemorrhage in these patients. However, it is unclear whether chemoprophylaxis can be safely initiated prior to stable repeat imaging. The objective of this study was to determine if early (ie, <24 h from presentation) deep venous thrombosis (DVT) chemoprophylaxis in patients with traumatic intracranial hemorrhage is safe.

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