Early initiation of prophylactic heparin in severe traumatic brain injury is associated with accelerated improvement on brain imaging

Abstract

Background: Venous thromboembolic prophylaxis (VTEp) is often delayed following traumatic brain injury (TBI), yet animal data suggest that it may reduce cerebral inflammation and improve cognitive recovery. We hypothesized that earlier VTEp initiation in severe TBI patients would result in more rapid neurologic recovery and reduced progression of brain injury on radiologic imaging.

Study design: Medical charts of severe TBI patients admitted to a level 1 trauma center in 2009-2010 were queried for admission Glasgow Coma Scale (GCS), head Abbreviated Injury Scale, Injury Severity Score (ISS), osmotherapy use, emergency neurosurgery, and delay to VTEp initiation. Progression (+1 = better, 0 = no change, -1 = worse) of brain injury on head CTs and neurologic exam (by bedside MD, nurse) was collected from patient charts. Head CT scan Marshall scores were calculated from the initial head CT results.

Results: A total of 22, 34, and 19 patients received VTEp at early (<3 days), intermediate (3-5 days), and late (>5 days) time intervals, respectively. Clinical and radiologic brain injury characteristics on admission were similar among the three groups (P > 0.05), but ISS was greatest in the early group (P < 0.05). Initial head CT Marshall scores were similar in early and late groups. The slowest progression of brain injury on repeated head CT scans was in the early VTEp group up to 10 days after admission.

Conclusion: Early initiation of prophylactic heparin in severe TBI is not associated with deterioration neurologic exam and may result in less progression of injury on brain imaging. Possible neuroprotective effects of heparin in humans need further investigation.

Keywords: Heparin; VTE prophylaxis; intracranial hemorrhage; traumatic brain injury.

Figure 1

Glasgow coma scale (GCS), head abbreviated Injury Scale (AIS), and head CT Marshall Score at admission to hospital (mean ± SEM, P > 0.05)

Figure 2

Injury severity score at admission to hospital (mean ± SEM, *P < 0.05 early vs. intermediate, †P < 0.05 early vs. late)

Figure 3

Emergent need for osmotherapy and surgery while the patient in the ED (mean ± SEM, P > 0.05)

Figure 4

Proportion of patients requiring osmotherapy and placement of a ventriculostomy (EVD) in the 10 days following admission (mean ± SEM, P > 0.05)

Figure 5

Cumulative clinical neurological changes based on serial nursing and physician documentation on daily progress notes. Positive deflection implies improvement, negative defl ection implies deterioration. For each patient at each time interval, progress notes were evaluated for change in neurological exam and a score of +1 (improvement), 0 (no change/no note documented), or −1 (deterioration) were averaged for the group (mean ± SEM, *P < 0.05 early vs. late)

Figure 6

Radiological progression of intracranial lesion as described in serial head CTs by attending neuroradiologists. Positive deflection implies improvement, negative deflection implies worsening. For each patient at each time interval, radiology records were queried for change in neurological exam and a score of +1 (improvement), 0 (no change/no scan done during this time frame) or −1 (worsening) were averaged for the group (mean ± SEM, *P < 0.05 early vs. late)