What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for patients with intracranial hemorrhage?

DVT Prophylaxis for Intracranial Hemorrhage

For patients with intracranial hemorrhage, intermittent pneumatic compression (IPC) devices should be started immediately upon admission, followed by pharmacological prophylaxis with low-dose unfractionated heparin (UFH) or low molecular weight heparin (LMWH) 24-48 hours after bleeding has been controlled. 1

Initial Management

Immediate Mechanical Prophylaxis

• Start intermittent pneumatic compression (IPC) devices on the day of diagnosis/admission 1
• Apply to thigh-high level 1
• Continue until patient becomes independently mobile, is discharged, develops adverse effects, or reaches 30 days (whichever comes first) 1

Contraindications to Mechanical Prophylaxis

• None specific to IPC in ICH patients
• Monitor for skin breakdown daily when using IPC 1
• Consider wound care specialist consultation if skin breakdown occurs 1

Pharmacological Prophylaxis

Timing

• Initiate low-dose UFH or LMWH 24-48 hours after ICH onset 1
• Document hemorrhage stability on CT before starting pharmacological prophylaxis 1
• Earlier initiation (≤48 hours) is associated with decreased VTE/DVT rates without increased risk of hemorrhage progression 2

Agent Selection

• LMWH (e.g., enoxaparin) is preferred over UFH 1
• Use UFH in patients with renal failure 1
• Enoxaparin has been shown to be superior to UFH in reducing VTE risk in traumatic brain injury 2

Important Considerations

Risk Assessment

• Assess all patients for VTE risk 1
• High-risk factors include:
  • Immobility (unable to move one or both lower limbs)
  • Unable to mobilize independently
  • Previous history of VTE
  • Dehydration
  • Comorbidities such as cancer 1

Monitoring

• Obtain repeat brain imaging to confirm hemorrhage stability before initiating pharmacological prophylaxis 1, 3
• Monitor for signs of hemorrhage expansion after starting pharmacological prophylaxis

What NOT to Do

• Do not use graduated compression stockings alone for VTE prophylaxis 1
  • Evidence shows they are not beneficial and may cause harm 1
• Do not routinely use inferior vena cava filters as thromboprophylaxis 1

Special Circumstances

Prolonged Immobility

• For patients remaining immobile beyond 30 days, continue pharmacological VTE prophylaxis 1

Patients with Established VTE

• For patients who develop proximal DVT or PE during acute ICH:
  • Consider temporary retrievable IVC filter as a bridge until anticoagulation can be initiated 1
  • Consider delaying treatment with therapeutic UFH or LMWH for 1-2 weeks after ICH onset 1

Evidence Quality and Pitfalls

• The safety of pharmacological prophylaxis within the first 24 hours remains uncertain 1, 3
• Most studies show that early pharmacological prophylaxis (24-48 hours) does not increase the risk of hemorrhage expansion 2, 4, 5
• The risk of VTE in ICH patients is 4 times higher than in ischemic stroke patients 1
• The in-hospital incidence of thromboembolic complications in ICH patients is approximately 7% 1
• Balancing the risk of hemorrhage expansion against the risk of VTE is critical - current evidence favors earlier rather than later prophylaxis 2, 3