Dengler Bradley A, Haight Thaddeus, Fu Adele, Hafeez Shaheryar J, Cirivello Michael, Bartanusz Viktor
1The Military Traumatic Brain Injury Initiative (MTBI), Bethesda, Maryland.
2Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland.
J Neurosurg. 2024 Nov 22;142(4):1046-1057. doi: 10.3171/2024.7.JNS232697. Print 2025 Apr 1.
There is continuing uncertainty about the safety of early chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI). The objective of this paper was to 1) calculate the risk of progression of posttraumatic intracranial hemorrhage (ICH) after VTE chemoprophylaxis, and 2) compare the probability of ICH progression in early versus late VTE prophylaxis.
The authors searched for English-language literature from database inception to January 2023. Two independent reviewers selected studies on post-TBI VTE chemoprophylaxis in hospitalized patients. Study parameters included ICH progression (as determined by follow-up imaging after starting chemoprophylaxis) in relation to use versus nonuse, timing, and type of VTE chemoprophylaxis. Pertinent variables included author, year, study type, demographic variables, cranial and systemic Injury Severity Scores, and data documenting ICH progression or indirect evidence of TBI worsening after the initiation of VTE chemoprophylaxis.
Thirty studies fulfilled the inclusion criteria. There was a 7.0% (95% CI 4.0%-10.0%) risk of CT-documented ICH progression following VTE chemoprophylaxis in the prophylactically treated group. There was no difference between the early versus late VTE prophylaxis groups for ICH progression (12 studies; OR 0.79 [95% CI 0.56-1.12]). There was also no significant difference in CT-documented ICH progression between the prophylactically treated and nontreated groups (5 studies; OR 0.57 [95% CI 0.28-1.18]).
The review of the literature shows that VTE chemoprophylaxis 72 hours after TBI is considered safe by the majority of authors. This meta-analysis did not reveal any evidence of increased risk of ICH when starting VTE chemoprophylaxis earlier, i.e., within 72 hours of TBI; however, it is important to emphasize that only a small number of lower-quality studies addressed the 48-hour or 24-hour time point. A randomized noninferiority trial should be the next step in answering the question of early (within 72 hours) VTE chemoprophylaxis after TBI.
创伤性脑损伤（TBI）患者早期进行静脉血栓栓塞症（VTE）化学预防的安全性一直存在不确定性。本文的目的是：1）计算VTE化学预防后创伤后颅内出血（ICH）进展的风险；2）比较早期与晚期VTE预防中ICH进展的概率。
作者检索了从数据库建立到2023年1月的英文文献。两名独立审稿人筛选了关于住院患者TBI后VTE化学预防的研究。研究参数包括与使用或不使用、时间和VTE化学预防类型相关的ICH进展情况（通过开始化学预防后的随访影像学确定）。相关变量包括作者、年份、研究类型、人口统计学变量、颅脑和全身损伤严重程度评分，以及记录ICH进展或VTE化学预防开始后TBI恶化间接证据的数据。
30项研究符合纳入标准。在接受预防性治疗的组中，VTE化学预防后CT记录的ICH进展风险为7.0%（95%CI 4.0%-10.0%）。早期与晚期VTE预防组在ICH进展方面无差异（12项研究；OR 0.79[95%CI 0.56-1.12]）。接受预防性治疗组与未治疗组在CT记录的ICH进展方面也无显著差异（5项研究；OR 0.57[95%CI 0.28-1.18]）。
文献综述表明，大多数作者认为TBI后72小时进行VTE化学预防是安全的。这项荟萃分析未发现更早开始VTE化学预防（即TBI后72小时内）会增加ICH风险的任何证据；然而，需要强调的是，只有少数质量较低的研究涉及48小时或24小时时间点。下一步应进行一项随机非劣效性试验，以回答TBI后早期（72小时内）VTE化学预防的问题。
