Adverse Outcomes With Early Venous Thromboembolism Prophylaxis in Neurosurgical Trauma Patients—Are We Crossing the Blood-Brain Barrier?

Abstract

The risk of worsening traumatic brain injury (TBI) by initiating venous thromboembolism (VTE) chemoprophylaxis creates a conundrum for medical practitioners involved in trauma and neurosurgery. A resurgence of evidence has reexamined the timing of VTE prophylaxis and has strongly advocated that early (24 to 72 hours postinjury) administration is safe and not associated with increased bleeding or mortality for those with radiologically proven stable intracranial injuries. 1,2 However, this research largely fails to adequately examine the subgroup of patients undergoing neurosurgical intervention and who are thus high risk by the Modified Berne-Norwood Criteria. 3 Logic serves that these patients may be categorically different in their response to VTE prophylaxis not only owing to the severity of their injury but risk of periprocedural hemorrhage. However, many current guidelines cite weak or inadequate data to make substantial recommendations regarding VTE prophylaxis, and none differentiate this population of patients from the larger group of those with TBI. [4][5][6] Here, Byrne and colleagues 7 present some of the first data examining the risks and benefits of VTE prophylaxis, specifically in patients with TBI undergoing neurosurgical interventions.The authors used the Trauma Quality Improvement Program database to examine early pharmacologic VTE prophylaxis in patients with TBI undergoing emergent neurosurgical intervention within the first 24 hours of presentation. Craniotomy/craniectomy, intracranial monitor/drain insertion, or both were considered as urgent neurosurgical interventions. As this was a retrospective database study, the authors used repeat neurosurgical intervention or in-hospital mortality as a surrogate marker for clinically significant worsening of intracranial hemorrhage. It is not surprising that early initiation of VTE prophylaxis led to decreased thromboembolic events. They demonstrated an 8% increase in odds of VTE with each additional day prophylaxis was delayed. What was surprising was that earlier ini-