Introduction: The use of pharmacologic prophylaxis (PP) for venous thromboembolism (VTE) in patients with spontaneous intracerebral hemorrhage (ICH) remains controversial. We hypothesized that PP is associated with improved outcome without elevated bleeding risk when compared to mechanical prophylaxis (MP) alone.
Methods: We conducted a prospective, observational study on patients >18 years admitted with ICH between 7/2008 and 11/2011. All patients received compression boots for MP at admission. PP utilization (heparin or enoxaparin) was under unit protocol at the discretion of the intensivist and neurosurgery team. Major hemorrhage complications including ICH expansion and new intracranial bleeding were recorded. VTE was diagnosed by ultrasound or chest CT angiogram. Multivariable logistic regression analysis was performed to assess independent predictors for a Modified Rankin Scale (mRS) 4-6 at 3 months follow-up.
Results: 125 patients were included in the analysis; 91 (73%) patients received PP and 34 (27%) patients received MP. Median days to receiving PP was 5 (interquartile range: 3,7) post-bleed and 3 (2,6) post-surgery. Baseline characteristics were similar between groups, including age, admission NIHSS, GCS, APACHE2 (Acute Physiology and Chronic Health Evaluation2), ICH volume, ICH score, and history of prior VTE. More patients in the PP group vs. the MP group underwent ventriculostomy placement (41% vs. 12%, p=0.005) and surgery (28% vs. 9%, p=0.03). The rate of VTE (p=0.7) and major hemorrhage (p=0.3) were similar between groups. At 3 month follow-up, 26 (77%) MP patients and 56 (62%) PP patients had a mRS4-6. After adjusting for NIHSS, ICH score, and APACHE2, PP was an independent predictor against mRS4-6 (odds ratio: 0.15, 95% confidence interval: 0.03-0.70).
Conclusions: In spontaneous ICH patients, pharmacologic prophylaxis for VTE compared to mechanical prophylaxis alone was associated with improved 3-month functional outcomes without an increased risk of major hemorrhage complications.
Patient Care: Our research suggests that pharmacologic prophylaxis for VTE in patients with spontaneous intracerebral hemorrhage can be used safely and effectively when compared with mechanical prophylaxis alone. Our findings will help guide clinicians in determining when to use pharmacologic prophylaxis in this population.
Learning Objectives: By the conclusion of this session participants should be able to:
1. Describe the risks and benefits associated with pharmacologic prophylaxis versus mechanical prophylaxis for venous thromboembolism in patients with spontaneous intracerebral hemorrhage.
2. Discuss in small groups how patient selection affects the utilization of pharmacologic prophylaxis versus mechanical prophylaxis for VTE in patients with spontaneous intracerebral hemorrhage.
3. Identify selection criteria for the use of pharmacologic prophylaxis in patients with spontaneous intracerebral hemorrhage.
References: 1. Geerts WH, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):381S-453S.
2. Goldstein JN, et al. Risk of thromboembolism following acute intracerebral hemorrhage. Neurocrit Care. 2009;10(1):28-34.
3. Wu TC, et al. Pharmacological deep vein thrombosis prophylaxis does not lead to hematoma expansion in intracerebral hemorrhage with intraventricular extension. Stroke. 2011 Mar;42(3):705-9.
4. Orken DN, et al. Prevention of deep venous thrombosis and pulmonary embolism in patients with acute intracerebral hemorrhage. Neurologist. 2009 Nov;15(6):329-31.
5. A Boeer, et al. Early heparin therapy in patients with spontaneous intracerebral hemorrhage. J Neurol Neurosurg Psychiatry. 1991 May; 54(5): 466–467.