Anticoagulation in patients with traumatic brain injury

A major challenge in the treatment of brain-injured patients is the decision on indication and timing of prophylactic anticoagulation. In addition, an increasing number of patients suffering from traumatic brain injury (TBI) are on preinjury anticoagulation therapy. Despite clear evidence for an increased risk of venous thromboembolic events and pulmonary embolism in traumatized patients without prophylactic anticoagulation, there is a lack of distinct recommendations and standardized clinical practice guidelines. This review summarizes current research evidence regarding post-traumatic prophylactic anticoagulation and management of patients with prehospital use of anticoagulants.

In addition to nonpharmacological techniques like compression stockings, use of low-dose unfractionated heparin or low-molecular-weight heparin is effective in different studies in terms of thromboprophylaxis. If follow-up computed tomography scans and clinical neurological examinations do not show progression within 24 h after initial evaluation, prophylactic anticoagulation does not increase risk for hemorrhage progression and therefore seems to be safe after TBI.

Stratification scores for identification of TBI patients with low, moderate, or high risk for spontaneous cerebral bleeding may help to allow early thromboprophylaxis while maintaining a good risk-benefit ratio. So far, these scores require validation by prospective trials. Therefore, current evidence requires control computed tomography scans prior to early pharmacological thromboprophylaxis.