Anticoagulation in patients with traumatic brain injury

Abstract

The incidence of venous thromboembolic events in trauma patients is highest during the first few days following hospitalization, and traumatic brain injury (TBI) represents an independent risk factor for venous thromboembolism (VTE). Up to 58% of patients with TBI may develop VTE in the absence of any form of prophylaxis and up to 30% with only mechanical prophylaxis. The time to resume or initiate pharmacological thromboprophylaxis (PTP) following TBI is controversial and depends on the evolution of intracranial hematoma on the follow-up head CT scan and the risk of further progression of hematoma. Spontaneous progression of hematoma (without PTP) was seen in 5 – 32% of patients, predominantly in patients with intraparenchymal contusion or intraventricular hemorrhage. In patients with stable intracranial hematoma on follow-up head CT scan PTP should be started within 24–48h, whereas therapeutic doses of anticoagulant drugs should be delayed for at least 12 days. The initiation of PTP during the first 3 days after the urgent surgical intervention is associated with increased risk of repeated neurosurgery, and is therefore not advised. The use of low molecular weight heparin has been associated with lower rates of heparin-induced thrombocytopenia, intracranial hematoma expansion and lower incidence of VTE compared to unfractionated heparin. Prophylaxis with unfractionated heparin may be the preferred agent in high-risk patients with expanding hemorrhagic TBI lesions. Because of low quality of data in the literature guidelines regarding the optimal time to PTP, agent and dose remain vague.

Keywords

• TRAUMATIC BRAIN INJURY
• PHARMACOLOGICAL THROMBOPROPHYLAXIS
• ANTICOAGULATION THERAPY
• RISK OF VENOUS THROMBOEMBOLISM
• INTRACRANIAL HEMORRHAGE PROGRESSION