DVT, Delayed Cranial Decompression Rates Following Low-Molecular-Weight Heparin in TBI

In an observational study, researchers compared the likelihood of delayed cranial decompression following the initiation of prophylactic unfractionated heparin vs low-molecular-weight heparin using the National Trauma Data Bank.

Deep vein thrombosis (DVT) prophylaxis using low-molecular-weight heparin (LMWH) correlated with decreased rates of DVTs and delayed cranial decompression in patients with traumatic brain injury (TBI) compared with unfractionated heparin (UH), according to study findings published in World Neurosurgery.

To prevent DVT, UH and LMWH are commonly used prophylactically following TBI. However, their risk for the development of intracranial hemorrhage (ICH) or worsening necessitating cranial decompression is not known, the researchers explained. The objective of the current study was to compare the likelihood of delayed cranial decompression following the use of prophylactic UH vs LMWH. The researchers used the National Trauma Data Bank (NTDB) for their observational study.

The researchers analyzed data from 2017 and 2018 obtained from the Trauma Quality Programs Participant Use File (TQPPUF) of the American College of Surgeon’s NTDB. They included 218,594 patients with TBI in this study — 61,998 (28.3%) of whom received UH and 156,596 (71.7%) of whom received LMWH) to prevent development of DVTs.

Of the 218,594 patients with TBI, 3376 (1.5%) required delayed cranial decompression via craniotomy or craniectomy following DVT prophylaxis. Approximately 1.7% of patients developed DVTs, 0.7% developed pulmonary embolisms (PEs), and 1% returned to the operating room.

Patients with TBI receiving LMWH demonstrated significantly lower rates of post-DVT-prophylaxis craniotomy or craniectomy than recipients of UH (odds ratio [OR], 0.13; 95% confidence interval [CI], 0.11-0.16; P <.001). Additionally, compared with patients on UH, patients on LMWH experienced lower occurrence rates of DVT (OR, 0.24; 95% CI, 0.21-0.27; P <.001), PE (OR, 0.41; 95% CI, 0.36-0.48; P <.001), and return to the operating room (OR, 0.48; 95% CI, 0.42-0.54; P <.001).

The study had several limitations the researchers acknowledged. Lack of data on post-DVT prophylaxis ICH progression made it difficult to ascertain if delayed cranial decompression following DVT prophylaxis exacerbated ICH. The retrospective, observational design using the TQIP database further limited inference of causality in the study. Additionally, the nonrandomization in this study allowed for selection bias to occur based on physician judgment of whether their patients with TBI should receive DVT prophylaxis and which medication to use.

“We demonstrate that, contrary to the anecdotal notion that UH may be safer for TBI given the existence of a specific reversal agent, LMWH was associated with significantly lower rates of postprophylaxis need for craniotomy or craniectomy,” the researchers stated. “We believe that this is a crucial datum to be further investigated in order to establish interdisciplinary consensus among clinicians in trauma, critical care, and neurosurgery regarding DVT prophylaxis in TBI.”

Disclosure: One study author declared affiliations for this study. Please see the original reference for a full list of disclosures.


Maragkos GA, Cho LD, Legome E, Wedderburn R, Margetis K. Delayed cranial decompression rates after initiation of unfractionated heparin versus low-molecular-weight heparin in traumatic brain injury. World Neurosurg. Published online June 9, 2022. doi:10.1016/j.wneu.2022.06.008