Mark N. Rubin, MD

Prabhakaran S, Herbers P, Khoury J, Adeoye O, Khatri P, Ferioli S, and Kleindorfer DO. Is Prophylactic Anticoagulation for Deep Venous Thrombosis Common PracticeAfter Intracerebral Hemorrhage? Stroke. 2015

Intracerebral hemorrhage (ICH), as has been discussed and re-discussed, is not only a terrible neurologic illness with exceedingly high morbidity and mortality, but systemically trying as well. Among the myriad complications that arise in the early period after ICH, venous thromboembolism (VTE) is perhaps chief among them given the potential morbidity and mortality, with one study suggesting a nearly four-fold increase in incidence as compared to ischemic strokes (1.9% vs 0.5%). This makes for an ostensibly difficult clinical conundrum, given the appropriate reluctance to anticoagulate – the preferred means of VTE prophylaxis – in the setting of ICH. However, given the suggestion that most ICH hematoma growth is in the first 24-48 hours from ictus, there is a guideline-based recommendation (albeit with a low level of evidence supporting it) to initiate low-dose heparin or heparinoid once a patient is 24-96 hours from the event and there has been demonstration of cessation of bleeding. Given the clinical dilemma of anticoagulating in the setting of a hemorrhage and the lack of high-level evidence to guide therapy, the current investigators conducted a nationwide survey to ascertain a gestalt of pharmacologic VTE prophylaxis in this country in the setting of ICH.

The survey was conducted in a standardized and structured fashion via an ICD-9-code-based database that includes all payer types (to expand the generalizability past, say, the Medicare population only), screening for adult ICH patients from 2006-2010. They found 32,690 patients meeting their inclusion criteria and, based on pharmacy records, only 5,395 (16.5%) received any prophylactic anticoagulation during the hospital stay. Among these patients, 2,416 (44.8%) received a dose by hospital day 2 and the dominating agent was unfractionated heparin (71.1% of those patients). Of interest, there was a trend toward increasing use of VTE prophylaxis over the study period (14.3% to 18% of patients) and there was a large variation in use by region, with the Northeast leading the way with 23.2%, the South 19%, the Midwest 10.8% and the West 9.8% of patients. Geographic location was the only independent predictor of prophylactic anticoagulation in their study.

This study has interesting implications not only for ICH practice but guideline-based initiatives for any clinical situation. Why are less than 20% of patients receiving what should be a safe intervention to prevent a major, life-ending complication? Is it only because some practitioners cannot get past the use of anticoagulants in the setting of a hemorrhage, in spite of an (albeit lacking) evidence-base and guideline to support the practice? Are these data and guidelines broadly accessible? Should this practice be under the kind of scrutiny we all know of when we care for other types of stroke (acute ischemic stroke in particular)? How does batting 0.200 compare to other guideline-based recommendations in acute neurology? Or any other specialty?