Venous thromboembolism (VTE) prevention has become a central focus of contemporary trauma care.1–3 There has been a shift toward early chemoprophylaxis; however, reservations persist regarding the optimal timing in patients with traumatic brain injury (TBI) given concerns for intracranial hemorrhage progression, which can be devastating. Understanding the optimal timing of chemoprophylaxis in TBI is particularly challenging as TBI is a highly heterogeneous disease process. Patients requiring neurosurgical intervention represent a subset of patients at a particularly high bleeding risk.
Using the Consortium of Leaders in Traumatic Thromboembolism database, the authors found that patients with TBI who underwent craniotomy or craniectomy and received VTE prophylaxis within 72 hours of admission had similar rates of VTE, adverse bleeding events, and progression of intracranial hemorrhage compared with those who received chemoprophylaxis after 72 hours.4 Analyses using 24- and 48-hour cut-off yielded the same results.
This study demonstrates that early VTE prophylaxis is a safe approach in this patient population. The American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma recommends starting VTE prophylaxis in accordance with the modified Berne-Norwood criteria, where patients with low-risk and medium-risk TBI features are started on chemoprophylaxis 24 hours and 72 hours after a stable head CT, respectively.5 Those with an intracranial pressure monitor, who have undergone a craniotomy, or who have evidence of progression at 72 hours should not be started on chemoprophylaxis; instead, they should be considered for serial duplexes and/or inferior vena cava filter placement. Arguably, withholding chemoprophylaxis in these patients is an antiquated practice. The Western Trauma Association states that nearly all patients can be started on chemoprophylaxis within 72 hours from injury; however, this recommendation is not specific to those undergoing neurosurgery interventions.6
The study by Wu et al provides important outcome data in a narrowly defined TBI population not directly addressed by existing guidelines. The upcoming fourth edition of the Brain Trauma Guidelines may further clarify optimal VTE prophylaxis strategies in this high-risk group.
