Early Venous Thromboembolism Prophylaxis in Patients with Trauma Intracranial Hemorrhage: Analysis of the Prospective Multicenter CLOTT Study.

BACKGROUND: The optimal time to initiate venous thromboembolism prophylaxis (VTEp) for patients with intracranial hemorrhage (ICH) is controversial and must balance the risks of VTE with potential progression of ICH. We sought to evaluate the efficacy and safety of early VTEp initiation after traumatic ICH.

METHODS: This is a secondary analysis of the prospective multicenter Consortium of Leaders in the Study of Thromboembolism (CLOTT) study. Patients with head AIS > 2 and with immediate VTEp held due to ICH were included. Patients were divided into VTEp ≤ or > 48 hours and compared. Outcome variables included overall VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), progression of ICH (pICH), or other bleeding events. Univariate and multivariate logistic regressions were performed.

RESULTS: There were 881 patients in total, 378 (43%) started VTEp ≤48 hours (early). Patients starting VTEp >48 hours (late) had higher VTE (12.4% vs 7.2%, p = .01) and DVT (11.0% vs 6.1%, p = .01) rates than the early group. The incidence of PE (2.1% vs 2.2%, p = .94), pICH (1.9% vs 1.8%, p = .95) or any other bleeding event (1.9% vs 3.0%, p = .28) were equivalent between early and late VTEp groups. On multivariate logistic regression analysis, VTEp >48 hours (OR 1.86), ventilator days >3 (OR 2.00), and risk assessment profile score ≥ 5 (OR 6.70) were independent risk factors for VTE (all p < 0.05), while VTEp with enoxaparin was associated with decreased VTE (OR 0.54, p < 0.05). Importantly, VTEp ≤48 hours was not associated with pICH (OR 0.75) or risk of other bleeding events (OR 1.28) (both p = NS).

CONCLUSIONS: Early initiation of VTEp (≤48 h) for patients with ICH was associated with decreased VTE/DVT rates without increased risk of pICH or other significant bleeding events. Enoxaparin is superior to unfractionated heparin as VTE prophylaxis in patients with severe TBI.

LEVEL OF EVIDENCE: Level IV; Therapeutic/Care management.