Risk of Ventriculostomy-Associated Hemorrhage in Patients with Aneurysmal Subarachnoid Hemorrhage Treated with Anticoagulant Thromboprophylaxis

Prevention of deep vein thrombosis in patients with aneurysmal subarachnoid hemorrhage: a best practice implementation project

INTRODUCTION

Deep vein thrombosis (DVT) is a common complication observed in aneurysmal subarachnoid hemorrhage (aSAH) patients, which significantly increases the survival risks and reduces the patient's quality of life. However, preventive clinical measures for DVT have not been standardized; therefore, the scientific basis and effectiveness of these measures require further validation.

OBJECTIVE

This study aims to employ evidence-based practices to effectively prevent the occurrence of DVT in aSAH patients.

METHODS

This study was performed from June 2023 to March 2024 in the neurosurgical intensive care unit of a Grade III Class A general hospital in Nanchang, China. Furthermore, it was based on the healthcare model published by the Joanna Briggs Institute Library (JBI) in 2016, which emphasizes the use of previous evidence-based practices while considering appropriateness, feasibility, clinical significance, and validity. In this research study, 15 review indicators were developed, and baseline assessments on 47 nurses and 49 patients were conducted. Furthermore, factors promoting and obstructing implementation were analyzed, and targeted strategies to address these obstacles were formulated. Moreover, a follow-up audit was performed to identify best practices.

RESULTS

The baseline review results indicated that the incidence of DVT in aSAH patients was 16.3%. Furthermore, the implementation rates of six review indicators (1, 2, 4, 5, 8, 13) were all < 100.0%, with indicators 2, 5, and 8 indicating < 60.0% implementation rates. After the project implementation, a subsequent audit revealed that the best practice initiative yielded significant improvements compared to the baseline data. Moreover, the incidence of lower limb DVT in aSAH patients decreased from 16.3% before the evidence-based practices to 6.1% after their implementation. At the nursing level, the DVT prevention knowledge and practice questionnaire scores increased from 63.62 ± 11.48 to 74.77 ± 9.98 after the evidence-based practices (t = -5.03, p < .001). In addition, the implementation rates of the six review indicators improved to varying degrees after the implementation of evidence-based practices (p < .050).

CONCLUSIONS

This project implemented evidence-based practices and indicated a reduced incidence of lower limb DVT in patients with aSAH. Furthermore, this study improved the knowledge, provided evidence for DVT prevention for the neurosurgical ICU nurses, promoted the implementation rate of review indicators for DVT prevention, standardized the behavior of neurosurgical ICU nurses for preventing DVT in aSAH patients, and ensured the safety of patients.

TRIAL REGISTRATION

This study has been registered at the EvidenceBased Nursing Center of Fudan University in China. Clinical trial number ER20230578.

Pharmacologic Venous Thromboembolism Prophylaxis in Patients with Nontraumatic Subarachnoid Hemorrhage Requiring an External Ventricular Drain

BACKGROUND

Optimal pharmacologic thromboprophylaxis dosing is not well described in patients with subarachnoid hemorrhage (SAH) with an external ventricular drain (EVD). Our patients with SAH with an EVD who receive prophylactic enoxaparin are routinely monitored using timed anti-Xa levels. Our primary study goal was to determine the frequency of venous thromboembolism (VTE) and secondary intracranial hemorrhage (ICH) for this population of patients who received pharmacologic prophylaxis with enoxaparin or unfractionated heparin (UFH).

METHODS

A retrospective chart review was performed for all patients with SAH admitted to the neurocritical care unit at Emory University Hospital between 2012 and 2017. All patients with SAH who required an EVD were included.

RESULTS

Of 1,351 patients screened, 868 required an EVD. Of these 868 patients, 627 received enoxaparin, 114 received UFH, and 127 did not receive pharmacologic prophylaxis. VTE occurred in 7.5% of patients in the enoxaparin group, 4.4% in the UFH group (p = 0.32), and 3.2% in the no VTE prophylaxis group (p = 0.08). Secondary ICH occurred in 3.83% of patients in the enoxaparin group, 3.51% in the UFH group (p = 1), and 3.94% in the no VTE prophylaxis group (p = 0.53). As steady-state anti-Xa levels increased from 0.1 units/mL to > 0.3 units/mL, there was a trend toward a lower incidence of VTE. However, no correlation was noted between rising anti-Xa levels and an increased incidence of secondary ICH. When compared, neither enoxaparin nor UFH use was associated with a significantly reduced incidence of VTE or an increased incidence of ICH.

CONCLUSIONS

In this retrospective study of patients with nontraumatic SAH with an EVD who received enoxaparin or UFH VTE prophylaxis or no VTE prophylaxis, there was no statistically significant difference in the incidence of VTE or secondary ICH. For patients receiving prophylactic enoxaparin, achieving higher steady-state target anti-Xa levels may be associated with a lower incidence of VTE without increasing the risk of secondary ICH.

Association between external ventricular drain removal or replacement and prophylactic anticoagulation in patients with aneurysmal subarachnoid hemorrhage: a propensity-adjusted analysis

BACKGROUND

Withholding prophylactic anticoagulation from patients with aneurysmal subarachnoid hemorrhage (aSAH) before external ventricular drain (EVD) removal or replacement remains controversial. This study analyzed whether prophylactic anticoagulation was associated with hemorrhagic complications related to EVD removal.

METHOD

All aSAH patients treated from January 1, 2014, to July 31, 2019, with an EVD placed were retrospectively analyzed. Patients were compared based on the number of prophylactic anticoagulant doses withheld for EVD removal (> 1 vs. ≤ 1). The primary outcome analyzed was deep venous thrombosis (DVT) or pulmonary embolism (PE) after EVD removal. A propensity-adjusted logistic-regression analysis was performed for confounding variables.

RESULTS

A total of 271 patients were analyzed. For EVD removal, > 1 dose was withheld from 116 (42.8%) patients. Six (2.2%) patients had a hemorrhage associated with EVD removal, and 17 (6.3%) patients had a DVT or PE. No significant difference in EVD-related hemorrhage after EVD removal was found between patients with  > 1 versus ≤ 1 dose of anticoagulant withheld (4 of 116 [3.5%] vs. 2 of 155 [1.3%]; p = 0.41) or between those with no doses withheld compared to ≥ 1 dose withheld (1 of 100 [1.0%] vs. 5 of 171 [2.9%]; p = 0.32). After adjustment, withholding > 1 dose of anticoagulant versus ≤ 1 dose was associated with the occurrence of DVT or PE (OR 4.8; 95% CI, 1.5-15.7; p = 0.009).

CONCLUSIONS

In aSAH patients with EVDs, withholding > 1 dose of prophylactic anticoagulant for EVD removal was associated with an increased risk of DVT or PE and no reduction in catheter removal-associated hemorrhage.

Compartmental Cerebrospinal Fluid Events Occurring after Subarachnoid Hemorrhage: An "Heparin Oriented" Systematic Review

Subarachnoid hemorrhage (SAH) represents a severe acute event with high morbidity and mortality due to the development of early brain injury (EBI), secondary delayed cerebral ischemia (DCI), and shunt-related hydrocephalus. Secondary events (SSE) such as neuroinflammation, vasospasm, excitotoxicity, blood-brain barrier disruption, oxidative cascade, and neuronal apoptosis are related to DCI. Despite improvement in management strategies and therapeutic protocols, surviving patients frequently present neurological deficits with neurocognitive impairment. The aim of this paper is to offer to clinicians a practical review of the actually documented pathophysiological events following subarachnoid hemorrhage. To reach our goal we performed a literature review analyzing reported studies regarding the mediators involved in the pathophysiological events following SAH occurring in the cerebrospinal fluid (CSF) (hemoglobin degradation products, platelets, complement, cytokines, chemokines, leucocytes, endothelin-1, NO-synthase, osteopontin, matricellular proteins, blood-brain barrier disruption, microglia polarization). The cascade of pathophysiological events secondary to SAH is very complex and involves several interconnected, but also distinct pathways. The identification of single therapeutical targets or specific pharmacological agents may be a limited strategy able to block only selective pathophysiological paths, but not the global evolution of SAH-related events. We report furthermore on the role of heparin in SAH management and discuss the rationale for use of intrathecal heparin as a pleiotropic therapeutical agent. The combination of the anticoagulant effect and the ability to interfere with SSE theoretically make heparin a very interesting molecule for SAH management.

Whether it is safe to start anticoagulation after intracranial hemorrhage within 2 weeks: A systematic review and meta-analysis

Whether restarting anticoagulation (RA) treatment after intracranial hemorrhage (ICH) is still controversial. We performed a systematic review and meta-analysis to summarize the relationship between anticoagulation after ICH with the recurrence of hemorrhagic events, ischemic events, and long-term mortality. Medline, Embase, and the Cochrane Central Register of Controlled Trials, from inception to November 2020. We searched the published medical literature to ensure cohort studies involving ICH associated with anticoagulation in adults. Primary outcomes were long-term mortality, hemorrhagic events, and ischemic events (myocardial infarction, pulmonary embolism, ischemic stroke, or systemic embolization). We concluded seven retrospective cohorts, including 1876 intracranial hemorrhage patients with indications of anticoagulation. The ratio of the anticoagulant restart was 35.3% (664n). RA was associated with a significantly lower incidence of recurrent ischemic events (pooled odds ratio [OR] 0.29, 95% confidence interval [CI] 0.19% to 0.45%, p = 0.97) and death events (pooled OR 0.56, 95% CI 0.40%-0.79%, p = 0.27). There is no evidence that early recovery of anticoagulation (within 2 weeks or 1 month) is associated with the occurrence of hemorrhagic events (within 2 weeks: pooled OR 0.80, 95% CI 0.3-2.12, p = 0.52 vs. within 1 month: pooled OR 1.14, 95% CI 0.77-1.68, p = 0.82). Based on these, recovery of anticoagulation after ICH is beneficial for long-term mortality and recurrence of ischemic events. The meta-analysis showed a resumption of oral anticoagulation within 2 weeks or 1 month in patients who had a cerebral hemorrhage was beneficial and did not increase the risk of hemorrhagic events and reduced the occurrence of ischemic and fatal endpoint events.

Multidisciplinary Bundle Approach in Venous Thromboembolism Prophylaxis in Patients with Non-Traumatic Subarachnoid Hemorrhage

Background

A venous thromboembolism (VTE) bundle was launched in 2016 at the University of Illinois Hospital aiming to reduce the rate of VTE in the neurosurgical ICU. Main elements of the bundle included correct and early use of intermittent pneumatic compression and subcutaneous heparin.

Methods

Patients with SAH were retrospectively identified from 2014 until 2018. VTE events were diagnosed using twice weekly lower-extremity venous Duplex ultrasound and chest computerized tomography when appropriate.

Results

A total of 133 patients was included in each group. The incidence of VTE was not significantly different before and after the bundle (15% vs. 12%, p = 0.47). No difference was found regarding new episode of intracranial hemorrhage secondary to SQH (1.5% vs. 2.1%, p = 0.65). Multivariate analysis demonstrated that longer ICU LOS, higher Caprini score, and presence of baseline lung diseases were associated with VTE development.

Conclusions

With a median Caprini score of 9, our patient population was found to be at high risk for developing VTE. The implementation of the VTE bundle did not significantly reduce the rate of VTE in patients with non-traumatic SAH at UIH.

Pharmacologic thromboprophylaxis in adult patients undergoing neurosurgical interventions for preventing venous thromboembolism

The impact of pharmacologic prophylaxis for venous thromboembolism in patients undergoing neurosurgical intervention remains uncertain. We reviewed the efficacy and safety of pharmacologic compared with nonpharmacologic thromboprophylaxis in neurosurgical patients. Three databases were searched through April 2018, including those for randomized controlled trials (RCTs) and for nonrandomized controlled studies (NRSs). Independent reviewers assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Seven RCTs and 3 NRSs proved eligible. No studies reported on symptomatic proximal and distal deep vein thrombosis (DVT). Two RCTs reported on screening-detected proximal and distal DVTs. We used the findings of these 2 RCTs as the closest surrogate outcomes to inform the proximal and distal DVT outcomes. These 2 RCTs suggest that pharmacologic thromboprophylaxis may decrease the risk of developing asymptomatic proximal DVT (relative risk [RR], 0.50; 95% confidence interval [CI], 0.30-0.84; low certainty). Findings were uncertain for mortality (RR, 1.27; 95% CI, 0.57-2.86; low certainty), symptomatic pulmonary embolism (PE) (RR, 0.84; 95% CI, 0.03-27.42; very low certainty), asymptomatic distal DVT (RR, 0.54; 95% CI, 0.27-1.08; very low certainty), and reoperation (RR, 0.43; 95% CI, 0.06-2.84; very low certainty) outcomes. NRSs also reported uncertain findings for whether pharmacologic prophylaxis affects mortality (RR, 0.72; 95% CI, 0.46-1.13; low certainty) and PE (RR, 0.18; 95% CI, 0.01-3.76). For risk of bleeding, findings were uncertain in both RCTs (RR, 1.57; 95% CI, 0.70-3.50; low certainty) and NRSs (RR, 1.45; 95% CI, 0.30-7.12; very low certainty). In patients undergoing neurosurgical procedures, low certainty of evidence suggests that pharmacologic thromboprophylaxis confers benefit for preventing asymptomatic (screening-detected) proximal DVT with very low certainty regarding its impact on patient-important outcomes.

Low-Dose Intravenous Heparin Infusion After Aneurysmal Subarachnoid Hemorrhage is Associated With Decreased Risk of Delayed Neurological Deficit and Cerebral Infarction

BACKGROUND

Patients who survive aneurysmal subarachnoid hemorrhage (aSAH) are at risk for delayed neurological deficits (DND) and cerebral infarction. In this exploratory cohort comparison analysis, we compared in-hospital outcomes of aSAH patients administered a low-dose intravenous heparin (LDIVH) infusion (12 U/kg/h) vs those administered standard subcutaneous heparin (SQH) prophylaxis for deep vein thrombosis (DVT; 5000 U, 3 × daily).

OBJECTIVE

To assess the safety and efficacy of LDIVH in aSAH patients.

METHODS

We retrospectively analyzed 556 consecutive cases of aSAH patients whose aneurysm was secured by clipping or coiling at a single institution over a 10-yr period, including 233 administered the LDIVH protocol and 323 administered the SQH protocol. Radiological and outcome data were compared between the 2 cohorts using multivariable logistic regression and propensity score-based inverse probability of treatment weighting (IPTW).

RESULTS

The unadjusted rate of cerebral infarction in the LDIVH cohort was half that in SQH cohort (9 vs 18%; P = .004). Multivariable logistic regression showed that patients in the LDIVH cohort were significantly less likely than those in the SQH cohort to have DND (odds ratio (OR) 0.53 [95% CI: 0.33, 0.85]) or cerebral infarction (OR 0.40 [95% CI: 0.23, 0.71]). Analysis following IPTW showed similar results. Rates of hemorrhagic complications, heparin-induced thrombocytopenia and DVT were not different between cohorts.

CONCLUSION

This cohort comparison analysis suggests that LDIVH infusion may favorably influence the outcome of patients after aSAH. Prospective studies are required to further assess the benefit of LDIVH infusion in patients with aSAH.

Low-Dose versus Therapeutic Range Intravenous Unfractionated Heparin Prophylaxis in the Treatment of Patients with Severe Aneurysmal Subarachnoid Hemorrhage After Aneurysm Occlusion

BACKGROUND

While prophylaxis with intravenous unfractionated heparin (UFH) can effectively prevent venous thromboembolism (VTE) during the neurocritical care of patients with severe aneurysmal subarachnoid hemorrhage (aSAH), the risk for intracranial bleeding complications might increase. Owing to this therapeutic dilemma, the UFH administration regimen in this critical patient population remains highly controversial.

METHODS

We performed a retrospective analysis of patients with severe aSAH (Fisher grade 3-4) receiving either low-dose (activated partial thromboplastin time [aPTT] <40 seconds) or therapeutic range (aPTT 50-60 seconds) UFH during intensive care unit (ICU) treatment after complete surgical/endovascular aneurysm occlusion. The primary outcome was the rate of bleeding/VTE complications and the investigation of potential risk factors.

RESULTS

This study series comprised 410 patients with aneurysmal SAH (aSAH), with a mean age of 54.7 ± 12.6 years, a male:female ratio of 1:2.2, and aSAH-associated intracerebral hemorrhage (ICH) in 33.2%. After complete aneurysm occlusion, 112 patients (27.3%) received therapeutic dose UFH and 298 patients (72.7%) received low-dose UFH. VTE events occurred in 5.4% of the low-dose UFH cohort and in 6.3% of the therapeutic dose UFH cohort, with no significant differences in the rate and severity of VTE events. However, an increase in initial SAH-associated ICH was significantly (P = 0.007) more frequent in the therapeutic dose cohort (18.8% vs. 3.4%). Heparin-induced thrombocytopenia (HIT) was the sole risk factor for VTE (P < 0.001), and both an aPTT ≥50 seconds under UFH administration (P = 0.007) and the initial presence of SAH-associated ICH (P = 0.035) were significant risk factors for intracranial bleeding complications.

CONCLUSIONS

Even in high-risk neurocritical patients with severe SAH and prolonged ICU treatment, low-dose UFH-administration for VTE prophylaxis is equally effective as therapeutic UFH administration and carries a lower risk of bleeding complications.

Hemorrhagic Complications Associated with Ventriculostomy in Patients Undergoing Endovascular Treatment for Intracranial Aneurysms: A Single-Center Experience

BACKGROUND

Currently, a complete understanding of post-ventriculostomy hemorrhagic complications in subarachnoid hemorrhage due to ruptured aneurysms remains unknown. The present study evaluates the impact of periprocedural risk factors on rates of external ventricular drain (EVD)-associated hemorrhage in the setting of endovascular treatment of intracranial aneurysms.

METHODS

A retrospective chart review of 107 patients who underwent EVD placement within 24 h of endovascular coiling was performed. CT of head without contrast was obtained after drain placement and before endovascular treatment. Post-procedural CT was also obtained within 48 h of embolization and was reviewed for new/worsened track hemorrhages. Chi-squared test was used in evaluation.

RESULTS

Ninety-three of the 107 patients reviewed met the inclusion criteria. Four (25%) of the 16 patients on antiplatelet medications at presentation experienced post-EVD hemorrhage compared to 11 (14.3%) of 77 that were not (p = 0.29). Of the 13 patients given intraprocedural antiplatelets, 3 (23.1%) demonstrated hemorrhage compared to 12 (15%) of 80 not administered these medications (p = 0.46). Further, of 36 patients with intraprocedural anticoagulation, 6 (16.7%) exhibited hemorrhage compared to 9 (15.8%) of 57 in those without (p = 0.91). In 17 patients who received DVT prophylaxis, 2 (11.8%) exhibited hemorrhage compared to 13 (17.1%) of 76 who did not (p = 0.59). No post-EVD hemorrhage had attributable neurologic morbidity.

CONCLUSION

Our results, demonstrating no significant risk factor related to EVD-associated hemorrhage rates, support the safety of EVD placement in the peri-endovascular treatment period.

The Extracranial Consequences of Subarachnoid Hemorrhage

BACKGROUND

Subarachnoid hemorrhage (SAH) is managed across the full spectrum of healthcare, from clinical diagnosis to management of the hemorrhage and associated complications. Knowledge of the pathogenesis and pathophysiology of SAH is widely known; however, a full understanding of the underlying molecular, cellular, and circulatory dynamics has still to be achieved. Intracranial complications including delayed ischemic neurologic deficit (vasospasm), rebleed, and hydrocephalus form the targets for initial management. However, the extracranial consequences including hypertension, hyponatremia, and cardiopulmonary abnormalities can frequently arise during the management phase and have shown to directly affect clinical outcome. This review will provide an update on the pathophysiology of SAH, including the intra- and extracranial consequences, with a particular focus on the extracranial consequences of SAH.

METHODS

We review the literature and provide a comprehensive update on the extracranial consequences of SAH that we hope will help the management of these cohort of patients.

RESULTS

In addition to the pathophysiology of SAH, the following complications were examined and discussed: vasospasm, seizures, rebleed, hydrocephalus, fever, anemia, hypertension, hypotension, hyperglycemia, hyponatremia, hypernatremia, cardiac abnormalities, pulmonary edema, venous thromboembolism, gastric ulceration, nosocomial infection, bloodstream infection/sepsis, and iatrogenic complications.

CONCLUSIONS

Although the intracranial complications of SAH can take priority in the initial management, the extracranial complications should be monitored for and recognized as early as possible because these complications can develop at varying times throughout the course of the condition. Therefore, a variety of investigations, as described by this article, should be undertaken on admission to maximize early recognition of any of the extracranial consequences. Furthermore, because the extracranial complications have a direct effect on clinical outcome and can lead to and exacerbate the intracranial complications, monitoring, recognizing, and managing these complications in parallel with the intracranial complications is important and would allow optimization of the patient's management and thus help improve their overall outcome.

Heparin and Heparin-Derivatives in Post-Subarachnoid Hemorrhage Brain Injury: A Multimodal Therapy for a Multimodal Disease

Pharmacologic efforts to improve outcomes following aneurysmal subarachnoid hemorrhage (aSAH) remain disappointing, likely owing to the complex nature of post-hemorrhage brain injury. Previous work suggests that heparin, due to the multimodal nature of its actions, reduces the incidence of clinical vasospasm and delayed cerebral ischemia that accompany the disease. This narrative review examines how heparin may mitigate the non-vasospastic pathological aspects of aSAH, particularly those related to neuroinflammation. Following a brief review of early brain injury in aSAH and heparin’s general pharmacology, we discuss potential mechanistic roles of heparin therapy in treating post-aSAH inflammatory injury. These roles include reducing ischemia-reperfusion injury, preventing leukocyte extravasation, modulating phagocyte activation, countering oxidative stress, and correcting blood-brain barrier dysfunction. Following a discussion of evidence to support these mechanistic roles, we provide a brief discussion of potential complications of heparin usage in aSAH. Our review suggests that heparin’s use in aSAH is not only safe, but effectively addresses a number of pathologies initiated by aSAH.