Battling the Conundrum of Bleeding and Clotting: Initiation of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury after Neurosurgical Intervention

BACKGROUND: There are no consensus guidelines demonstrating that early venous thromboembolism prophylaxis (VTEP) is safe in patients with traumatic brain injury (TBI) who undergo neurosurgical interventions. We hypothesized that early initiation of VTEP in patients with TBI would decrease the incidence of venous thromboembolism (VTE) and intracranial hemorrhage expansion (ICHE). STUDY DESIGN: This was a retrospective single-center study of adult patients with TBI who underwent neurosurgical intervention from 2012 to 2023 at a level 1 trauma center. Early (72 hours or less) and late (more than 72 hours) VTEP initiation after neurosurgery were compared. Outcomes were VTE, ICHE, and mortality. A Cox proportional hazard regression was completed comparing late and early and VTEP vs No VTEP groups. RESULTS: Of 845 patients, 618 received VTEP, 180 received VTEP within 72 hours and 438 received VTEP more than 72 hours after neurosurgical intervention. There were no differences in age, race, sex, Abbreviated Injury Scale head score, or comorbidities. There was no difference in VTE (hazard ratio [HR] 1.38, 95% CI 0.39 to 4.84, p = 0.62). The Late cohort had lower odds of ICHE (HR 0.53, 95% CI 0.28 to 0.99, p = 0.05) and mortality (HR 0.04, 95% CI 0.24 to 0.80, p = 0.007). Increased risk of VTE of 50% with each missed dose was seen up to 3 missed doses (odds ratio 1.52, 95% CI 0.64 to 3.40, p = 0.31). CONCLUSIONS: Although VTE rates were similar between early and late chemoprophylaxis initiation in patients with TBI who underwent neurosurgical intervention, the late cohort had lower mortality and risk of ICHE. Missed doses had an increased risk of VTE.