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A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury

  • Joseph Margolick (a1), Charlotte Dandurand (a2), Katrina Duncan (a1), Wenjia Chen (a3), David C. Evans (a1), Mypinder S. Sekhon (a4), Naisan Garraway (a1), Donald E. G. Griesdale (a4), Peter Gooderham (a2) and S. Morad Hameed (a1)...

Abstract

Background: Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous thromboprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the postinjury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion. Methods: MEDLINE and EMBASE databases were searched. Inclusion criteria were studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers’ levels of evidence. Randomized controlled trials were assessed for bias according to the Cochrane Collaboration Tool and Cohort studies were evaluated for bias using the Newcastle-Ottawa Scale. We performed univariate meta-regression analysis in an attempt to identify a relationship between VTEp timing and hemorrhagic progression and assess study heterogeneity using an I 2 statistic. Results: Twenty-one studies were included in the systematic review. Eighteen total studies demonstrated that VTEp postinjury in patients with stable head computed tomography scan does not lead to TBI progression. Fourteen studies demonstrated that VTEp administration 24 to 72 hours postinjury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive intracranial hemorrhage. Overall, meta-regression analysis demonstrated that there was no relationship between rate of hemorrhagic progression and VTEp timing. Conclusions: Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.

Revue systématique des risques et des bénéfices de la prophylaxie des tromboembolies veineuses chez les patients atteints d’une lésion cérébrale traumatique. Contexte : Les patients qui ont subi une lésion cérébrale traumatique (LCT) présentent un risque accru de tromboembolie veineuse (TEV). Cependant, l’amorce de la tromboprophylaxie veineuse pharmacologique (TEVp) peut aggraver une hémorragie intracrânienne. Nous avons revu la littérature afin de déterminer le moment après le traumatisme où la TEVp peut être administrée sans risque de provoquer une évolution de la TEV et une expansion de l’hématome. Méthodologie : Nous avons effectué une recherche dans MEDLINE et dans EMBASE pour identifier des études sur le moment où la TEVp avait été administrée et la sécurité de la TEVp chez des patients atteints d’un LTC qui ne prenaient pas d’anticoagulants oraux antérieurement. Deux chercheurs ont recueilli les données et évalué le niveau de preuve. Le Cochrane Collaboration Tool a été utilisé pour détecter les biais dans les études contrôlées et randomisées et l’échelle de Newcastle-Ottawa a été utilisée pour évaluer les biais dans les études de cohorte. Nous avons eu recours à une analyse de méta-régression univariée pour tenter d’identifier une relation entre le moment où la TEVp avait été administrée et la progression de l’hémorragie et nous avons évalué l’hétérogénéité des études au moyen de la statistique I 2 . Résultats : Vingt-et-une études ont été incluses dans cette revue systématique. Dans dix-huit études, la TEVp administrée après le traumatisme chez des patients dont le scan à la tomodensitométrie de la tête était stable n’avait pas provoqué de progression de la LTC. Selon 14 études, l’administration de la TEVp 24 à 72 heures après le traumatisme est sûre chez les patients dont la lésion est stable. Quatre études suggéraient que l’administration de la TEVp dans les 24 heures de la blessure, chez les patients dont la LTC est stable, n’entraîne pas de progression d’une hémorragie intracrânienne. Globalement, l’analyse de méta-régression a démontré qu’il n’existait pas de relation entre le taux de progression de l’hémorragie et le moment d’administration de la TEVp. Conclusions : Selon la littérature, la TEVp peut être administrée sans danger 24 à 48 heures après un traumatisme chez les patients dont le risque d’hémorragie est faible et la lésion s’avère stable à l’imagerie.

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Copyright

Corresponding author

Correspondence to: S. Morad Hameed, Department of Surgery, University of British Columbia, Trauma Services 855 W 12th Ave Vancouver, BC, V5Z 1M9. Email: morad.hameed@vch.ca.

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