Between Scylla and Charybdis: risks of early therapeutic anticoagulation for venous thromboembolism after acute intracranial hemorrhage

Abstract

Objective

To assess the risk of hematoma expansion in patients with acute intracranial hemorrhage (ICH) requiring therapeutic anticoagulation for the treatment of venous thromboembolism.

Methods

We retrospectively reviewed all patients at our institution between 2014 and 2019 who were therapeutically anticoagulated for venous thromboembolism within 4 weeks after ICH. We included subtypes of traumatic ICH and spontaneous intraparenchymal hemorrhage. Our main outcome was the incidence of hematoma expansion within 14 days from initiating therapeutic anticoagulation. Hematoma expansion was defined as (1) radiographically proven expansion leading to cessation of therapeutic anticoagulation or (2) death due to hematoma expansion. Secondary outcomes included mortality due to hematoma expansion and characteristics associated with hematoma expansion.

Results

Fifty patients met inclusion criteria (mean age: 54 years, 80% male, 76% Caucasian); 24% had undergone a neurosurgical procedure prior to therapeutic anticoagulation. Median time from ICH to therapeutic anticoagulation initiation was 9.5 days (IQR 4–17), 40% received therapeutic anticoagulation in <7 days after ICH. Six patients (12%) developed hematoma expansion, of whom two (4%) died. While not statistically significant, patients with hematoma expansion tended to be older (57.8 vs. 53.5 years), were anticoagulated sooner (4 vs. 10 days), presented with lower GCS (50% vs. 39% with GCS <8), higher hematoma volume (50% vs. 42% >30 cc), and higher SDH diameter (16 mm vs. 8.35 mm). There was a trend towards greater risk of hematoma expansion for patients undergoing endoscopic ICH evacuation (16% vs. 2%, p = 0.09); patients with hematoma expansion were more likely to present with hydrocephalus (67% vs. 16%, p = 0.02).

Conclusions

Our study is among the first to explore characteristics associated with hematoma expansion in patients undergoing therapeutic anticoagulation after acute ICH. Larger studies in different ICH subtypes are needed to identify determinants of hematoma expansion in this high-acuity population.

Keywords:

• Intracranial hemorrhage
• traumatic brain injury
• therapeutic anticoagulation
• venous thromboembolism
• pulmonary embolism

Acknowledgements

We would like to acknowledge Ellen Robinson, Dr. Anneliese Schleyer, and Dr Joseph Cuschieri for their guidance in developing this project, and for allowing us to use the VTE screening tool. We would also like to acknowledge Dr. Nicolas Poilvert for assistance with figures and input in developing the study.

Authors’ contributions

TN conceived and designed the study with guidance from SW. Data collection was performed by TN, PC, PVP, and SW. Data analysis was performed by TN, PC, PVP, and SW. Statistical analyses were performed by MS with input from SW. TN and SW composed the manuscript, with editorial comments by RHB, PC, PVP and CJC.

Disclosure statement

The authors of this study have no pertinent conflict of interest to disclose.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The authors received no direct funding for this work. MS received support from NIMH [K01MH115789]. CC is supported by NINDS [NS09942].