1233. Systematic Review of Venous Thromboembolism Prophylaxis Strategies in Patients with Intracerebral Hemorrhage

Authors: Kwanza Tamu Warren; Tyler Schmidt, MD; Brian Ayers; Kristopher Kimmell, MD; G. Vates; Thomas Mattingly, MD, MS (Rochester, NY)

Introduction: Venous thromboembolism (VTE) is a frequent complication of intracerebral hemorrhage (ICH) and can result in significant morbidity and mortality. Several strategies exist for VTE prophylaxis including mechanical prophylaxis (MP), low-molecular-weight heparin (LMWH), and unfractionated heparin (UFH). The current guidelines from the AHA/ASA recommend MP in all ICH patients and state that chemical prophylaxis may be considered in patients with hemiplegia. However, the relative risks and benefits of VTE prophylaxis strategies have not been well assessed. The purpose of this study is to review safety and efficacy of various VTE prophylaxis strategies in ICH patients. Methods: A literature search was conducted on PubMed for VTE prophylaxis in patients with ICH. Articles that reported type of prophylaxis and outcomes were included. Efficacy was determined by VTE rates and safety determined by rates of hematoma enlargement. Results: Seven of the 170 studies met eligibility criteria. Two studies evaluated LMWH, four studies evaluated UFH, and one study evaluated MP alone. Overall VTE probability was 2.59% for LMWH, 6.95% (95% CI +/- 10.1%) for UFH, and 9.27% for MP. Compared to patients without prophylaxis, the NNT for LMWH was 17.59, 75.76 for UFH, and event rates were comparable in those without prophylaxis and MP. Overall risk of hematoma expansion was 7.12% (95% CI +/- 6.7%) with LMWH and 7.16% (95% CI +/- 7.3%) with UFH. Compared to patients without prophylaxis, the NNH for LMWH was 2509 and 1259 for UFH. Conclusion: ICH patients who do not receive prophylaxis develop VTE in up to 40% of cases. This study demonstrates evidence that chemical VTE prophylaxis with either LMWH or UFH is superior to MP alone in prevention of VTE. Despite current guidelines, these results suggest that chemical prophylaxis can lower risk of VTE without a comparable increase in risk of hematoma expansion.