In-Hospital Mortality and Hemorrhagic Risks in Traumatic Brain Injury Patients with Early vs. Late Venous Thromboembolism

Abstract

Objective

This study reviewed the management and outcomes of traumatic brain injury (TBI) patients who developed venous thromboembolism (VTE) during hospitalization, focusing on the timing of VTE diagnosis and anticoagulation initiation.

Methods

This retrospective, single-center study utilized data from the University of Texas Trauma Database. Patients were categorized based on VTE diagnosis timing (early ≤7 days, late >7 days). The primary outcome was in-hospital mortality. Secondary outcomes included mortality specifically among patients who were receiving anticoagulation treatment, hemorrhagic complications, predictors associated with early anticoagulation initiation (defined as ≤ 7 days from VTE diagnosis), and whether anticoagulation timing influenced mortality.

Results

Among 237 patients (early: 145, late: 92), the mean age was 59 ± 20 years vs. 55 ± 20 years (p = 0.133). Males comprised 68% vs. 78% (p = 0.038). Subdural hematomas were the predominant injury (63% vs. 68%, p = 0.443). In-hospital mortality was similar (10% vs. 13%, p = 0.524) and did not differ between anticoagulated and non-anticoagulated patients (p = 0.94). Among patients who died, 73% in the early group and 100% in the late group had received anticoagulation (p = 0.053). Hemorrhage expansion was more frequent in early VTE patients (40% vs. 0%, p = 0.046). Pulmonary embolism was associated with early anticoagulation (OR = 1.86, 95% CI: 1.09–3.17, p = 0.023), while severe neurologic injury (GCS <9) reduced its likelihood (OR = 0.53, 95% CI: 0.28–0.98, p = 0.042).

Conclusion

In-hospital mortality did not differ by VTE timing or anticoagulation status. However, hemorrhage expansion was more frequent in early VTE patients, particularly those with subdural hematomas, emphasizing the need for individualized anticoagulation strategies.

Keywords

traumatic brain injury - venous thromboembolism - anticoagulation - subdural hematoma

Publikationsverlauf

Eingereicht: 25. Januar 2025

Angenommen: 24. April 2025

Artikel online veröffentlicht:
18. Juni 2025

• References

• 1 Anderson FA, Spencer FA. Risk factors for venous thromboembolism. Circulation 2003; 107 (23, Suppl 1): 19-16
• 2 Nicolaides AN, Irving D. Clinical factors and the risk of deep venous thrombosis. In: Thromboembolism. Springer Netherlands; 1975: 193-204
• 3 Gillum RF. Pulmonary embolism and thrombophlebitis in the United States, 1970-1985. Am Heart J 1987; 114 (05) 1262-1264
• 4 Geller AI, Shehab N, Lovegrove MC, Weidle NJ, Budnitz DS. Bleeding related to oral anticoagulants: trends in US emergency department visits, 2016-2020. Thromb Res 2023; 225: 110-115
• 5 Guo S, Han R, Chen F. et al. Epidemiological characteristics for patients with traumatic brain injury and the nomogram model for poor prognosis: an 18-year hospital-based study. Front Neurol 2023; 14: 1138217
• 6 Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994; 331 (24) 1601-1606
• 7 Lilienfeld DE, Chan E, Ehland J, Godbold JH, Landrigan PJ, Marsh G. Mortality from pulmonary embolism in the United States: 1962 to 1984. Chest 1990; 98 (05) 1067-1072
• 8 Knudson MM, Ikossi DG, Khaw L, Morabito D, Speetzen LS. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg 2004; 240 (03) 490-496 , discussion 496–498
• 9 Laroche M, Kutcher ME, Huang MC, Cohen MJ, Manley GT. Coagulopathy after traumatic brain injury. Neurosurgery 2012; 70 (06) 1334-1345
• 10 Cohen DB, Rinker C, Wilberger JE. Traumatic brain injury in anticoagulated patients. J Trauma 2006; 60 (03) 553-557
• 11 Mina AA, Knipfer JF, Park DY, Bair HA, Howells GA, Bendick PJ. Intracranial complications of preinjury anticoagulation in trauma patients with head injury. J Trauma 2002; 53 (04) 668-672
• 12 Bajsarowicz P, Prakash I, Lamoureux J. et al. Nonsurgical acute traumatic subdural hematoma: what is the risk?. J Neurosurg 2015; 123 (05) 1176-1183
• 13 Pandya U, Pattison J, Karas C, O'Mara M. Does the presence of subdural hemorrhage increase the risk of intracranial hemorrhage expansion after the initiation of antithrombotic medication?. Am Surg 2018; 84 (03) 416-421
• 14 Hawryluk GWJ, Austin JW, Furlan JC, Lee JB, O'Kelly C, Fehlings MG. Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk. J Thromb Haemost 2010; 8 (07) 1500-1508
• 15 Yuan F, Ding J, Chen H. et al. Predicting progressive hemorrhagic injury after traumatic brain injury: derivation and validation of a risk score based on admission characteristics. J Neurotrauma 2012; 29 (12) 2137-2142
• 16 Matsushima K, Inaba K, Cho J. et al. Therapeutic anticoagulation in patients with traumatic brain injury. J Surg Res 2016; 205 (01) 186-191
• 17 Yadav YR, Basoor A, Jain G, Nelson A. Expanding traumatic intracerebral contusion/hematoma. Neurol India 2006; 54 (04) 377-381
• 18 Albrecht JS, Liu X, Baumgarten M. et al. Benefits and risks of anticoagulation resumption following traumatic brain injury. JAMA Intern Med 2014; 174 (08) 1244-1251
• 19 Oertel M, Kelly DF, McArthur D. et al. Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury. J Neurosurg 2002; 96 (01) 109-116
• 20 Kia M, Saluja RS, Marcoux J. Acute traumatic subdural hematoma and anticoagulation risk. Can J Neurol Sci 2023; 50 (02) 188-193
• 21 Narayan RK, Maas AIR, Servadei F, Skolnick BE, Tillinger MN, Marshall LF. Traumatic Intracerebral Hemorrhage Study Group. Progression of traumatic intracerebral hemorrhage: a prospective observational study. J Neurotrauma 2008; 25 (06) 629-639
• 22 Divito A, Kerr K, Wilkerson C, Shepard S, Choi A, Kitagawa RS. Use of anticoagulation agents after traumatic intracranial hemorrhage. World Neurosurg 2019; 123: e25-e30
• 23 Byrnes MC, Irwin E, Roach R, James M, Horst PK, Reicks P. Therapeutic anticoagulation can be safely accomplished in selected patients with traumatic intracranial hemorrhage. World J Emerg Surg 2012; 7 (01) 25
• 24 Jung HS, Jeon IC, Chang CH, Jung YJ. Effect of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk. J Korean Neurosurg Soc 2014; 55 (02) 69-72
• 25 Kawamata T, Takeshita M, Kubo O, Izawa M, Kagawa M, Takakura K. Management of intracranial hemorrhage associated with anticoagulant therapy. Surg Neurol 1995; 44 (05) 438-442 , discussion 443
• 26 Wijdicks EFM, Schievink WI, Brown RD, Mullany CJ. The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves. Neurosurgery 1998; 42 (04) 769-773
• 27 Matsushima K, Leichtle SW, Wild J, Young K, Chang G, Demetriades D. EAST ACT-TBI Multicenter Study Group. Anticoagulation therapy in patients with traumatic brain injury: an Eastern Association for the Surgery of Trauma multicenter prospective study. Surgery 2021; 169 (02) 470-476
• 28 Wilson JM, Shelvin KB, Lawhon SE, Crabill GA, Hayden EA, Velander AJ. Safety and timing of early therapeutic anticoagulation therapy after craniotomy. Surg Neurol Int 2024; 15: 31
• 29 Samuel S, Menchaca C, Gusdon AM. Timing of anticoagulation for venous thromboembolism after recent traumatic and vascular brain Injury. J Thromb Thrombolysis 2023; 55 (02) 289-296