Is it safe to start heparin for DVT prophylaxis given the latest CT head findings showing effacement of the left lateral ventricle and mild midline shift after an Intracerebral Hemorrhage (ICH)?

Management of Heparin DVT Prophylaxis After ICH with Midline Shift

Heparin DVT prophylaxis should be temporarily discontinued due to the new CT findings showing effacement of the left lateral ventricle and mild midline shift, which indicate potential hemorrhage progression or increased mass effect. 1

Assessment of Current Situation

The latest CT head findings showing effacement of the left lateral ventricle and mild midline shift represent a change from the previous "stable left parenchymal hemorrhage with minimal midline shift." This change suggests:

• Possible hemorrhage expansion
• Increased cerebral edema
• Worsening mass effect

Management Algorithm

1. Immediate Action:

   • Hold heparin DVT prophylaxis temporarily
   • Obtain neurosurgical consultation
   • Consider repeat CT head in 24 hours to assess stability

2. Decision Points:

   • If follow-up CT shows stabilization: Resume heparin prophylaxis
   • If follow-up CT shows continued expansion: Continue to hold heparin and consider other interventions

Evidence-Based Rationale

The 2022 AHA/ASA guidelines for ICH management emphasize that:

• Timing of DVT prophylaxis should maximize benefits while minimizing risk of hemorrhage expansion
• It is reasonable to first document hemorrhage stability on CT before initiating or continuing LMWH prophylaxis 1
• Hematoma size is independently associated with hemorrhage expansion 1

The guidelines specifically state that "it may be reasonable to first document hemorrhage stability on CT if LMWH prophylaxis is started in the 24- to 48-hour window after ICH onset." 1 This same principle applies when there are new concerning findings on follow-up imaging.

Risk-Benefit Analysis

Risks of continuing heparin:

• Potential for hemorrhage expansion
• Worsening of mass effect and midline shift
• Increased intracranial pressure
• Neurological deterioration

Risks of discontinuing heparin:

• Increased risk of DVT/PE (approximately 7% incidence in ICH patients) 1
• The risk is particularly high in immobile patients

Timing of Resumption

If follow-up imaging shows hemorrhage stability:

• Resume prophylactic-dose heparin after 24-48 hours of documented stability 1
• Consider using intermittent pneumatic compression devices in the interim 1

Common Pitfalls to Avoid

1. Misinterpreting "stable" hemorrhage: Effacement of ventricles and midline shift represent a change in the patient's status that warrants caution.

2. Overestimating the safety of prophylactic dosing: Even low-dose heparin can potentially worsen intracranial bleeding in unstable patients 2.

3. Delaying prophylaxis too long: Once stability is confirmed, prompt resumption of DVT prophylaxis is important as ICH patients have 4 times higher risk of DVT than those with ischemic stroke 1.

4. Relying solely on compression stockings: Evidence shows that compression stockings alone are not effective for DVT prophylaxis in ICH patients 1.

Alternative Approaches During Heparin Hold

• Intermittent pneumatic compression devices are recommended as first-line prophylaxis during periods when pharmacological prophylaxis is contraindicated 1
• Consider inferior vena cava filter placement only if there is documented proximal DVT and anticoagulation is absolutely contraindicated for an extended period 3

Remember that the decision to restart heparin should be based on documented stability of the hemorrhage on repeat imaging, as hematoma size and stability are the key factors in determining safety of pharmacological DVT prophylaxis.