ORIGINAL ARTICLE Incidence and Risk Factors for Deep Venous Thrombosis After Moderate and Severe Brain Injury Akpofure Peter Ekeh, MD, MPH, FACS, Kathleen M. Dominguez, MD, Ronald J. Markert, PhD, and Mary C. McCarthy, MD, FACS Background: Patients with traumatic injuries possess a high risk of developing deep venous thrombosis (DVT), thus the need for appropriate prophylaxis. Patients with head injuries pose a unique challenge due to contraindication to the use of anticoagulation. We sought to determine the incidence of DVT and identify specific risk factors for its development in patients with head injuries. Methods: All head injury admissions between January 1, 2000, and July 31, 2006, with a length of stay 7 days were identified. Patient data including age, sex, injuries, Glasgow Coma Scale, Injury Severity Score (ISS), and venous duplex scan results were collected. Mechanical methods were rou- tinely used for prophylaxis; heparin was not used in this population. Weekly duplex screening was commenced at 7 days to10 days after admission. Results: There were 939 patients who met criteria for review, however, duplex scans were performed in only 677, which was the population studied. Overall, DVT was present in 31.6%. There were fewer DVTs in patients with isolated head injuries (25.8%) compared with patients with those with head and extracranial injuries (34.3%)—p = 0.026. Independent predictors for DVT identified included male gender (p = 0.04), age 55 (p  0.001), ISS 15 (p = 0.014), subarachnoid hemorrhage (p = 0.006), and lower extrem- ity injury (p = 0.001). Conclusions: DVT occurs in one third of moderately to severely brain injured patients. Isolated head injuries have a lower incidence. Older age, male gender, higher ISS, and the presence of a lower extremity injury are strong predictors for developing DVT. Regular screening and the use of prophylactic inferior vena cava filters in patients with risk factors should be strongly considered. Key Words: Brain injury, Deep venous thrombosis, Incidence, Risk factors, Prophylaxis. (J Trauma. 2010;68: 912–915) V enous thromboembolic disease constitutes a spectrum of acquired coagulopathic disorders—ranging from superfi- cial thrombophlebitis and deep venous thrombosis (DVT) to pulmonary embolism (PE). DVT may present in a symptom- atic or occult fashion and can result in varying sequelae— ranging from complete resolution to fatal PE. 1 The morbidity and mortality associated with venous thromboembolic disor- ders translate into increased medical cost. 2,3 Injured patients have been recognized to be at increased risk for developing DVT and PE, when compared with regular hospital populations. 3–5 The prevalence of DVT has been esti- mated at 40% to 80% in major trauma patients not receiving prophylaxis. 4,5 The triad of stasis, hypercoagulability, and endo- thelial injury described by Virchow in 1856 are believed to be a central explanation for the increased risk pattern. Patients with head injures pose a unique management challenge with regard to DVT and PE prophylaxis. Because of the risk of bleeding associated with the use of anticoagulant therapy, many clinicians are hesitant to use anticoagulant prophylaxis in the presence of intracranial hemorrhage. 1,2,4,6,7 Several studies have examined various facets of DVT and PE in trauma patients, but few have specifically addressed the subset of patients with head injuries. We sought to determine the incidence of DVT in patients with head injures, compare its incidence in patients with isolated head injures with patients with combined head and extracranial injuries, and to identify unique risk factors for the development of DVT in this population. Most previ- ous studies in this area have not specifically examined the DVT incidence particularly in isolated head injuries. METHODS All adult (18 years) patients admitted to the Miami Valley Hospital (MVH), Dayton, OH between January 1, 2000, and July 31, 2006, with head injuries and a hospital length of stay (LOS) 7 days were identified from the trauma registry (TraumaBase, Clinical Data Management, Ever- green, CO). MVH is an American College of Surgeons verified level I trauma center. Patients with “concussions” but no identified anatomic brain injury on head computed tomog- raphy scan were excluded. Patient charts were reviewed, and data including age, sex, mechanism of injury, sustained injuries, Glasgow Coma Scale, Injury Severity Score (ISS), intensive care unit (ICU) LOS, overall LOS, and complications were collected. In this time period, per institutional protocol, sequential compression devices (SCDs) were routinely used for prophy- laxis for all patients admitted to the trauma service. Low mo- lecular weight heparins (LMWH) or unfractionated heparin were not used in patients with brain injuries. DVT screening of the lower extremities was performed, also per institutional protocol, by venous duplex ultrasound (US) scanning starting at 7 days to 10 days after admission and weekly thereafter. The duplex US’ were performed by qualified, licensed US technologists. Patients who manifested clinical evidence of Submitted for publication December 1, 2008. Accepted for publication April 15, 2009. Copyright © 2010 by Lippincott Williams & Wilkins From the Division for Trauma, Critical Care and Emergency General Surgery, Department of Surgery, Wright State University, Dayton, Ohio. Address for reprints: Akpofure Peter Ekeh, MD, MPH, FACS, Miami Valley Hospital, CHE 7000, 1 Wyoming Street, Dayton, OH 45409; email: peter. ekeh@wright.edu. DOI: 10.1097/TA.0b013e3181b21cad 912 The Journal of TRAUMA ® Injury, Infection, and Critical Care • Volume 68, Number 4, April 2010