CLINICAL ARTICLE J Neurosurg 126:1047–1055, 2017 T HE association between traumatic brain injury (TBI) and hypercoagulability is well established, but ve- nous thromboembolism (VTE) chemoprophylaxis (VTC) strategies remain controversial. Traumatic brain injury itself may confer as much as a 4-fold increased risk of deep vein thrombosis (DVT) in trauma patients. 13 In a study of 88 TBI patients with admission Glasgow Coma Scale (aGCS) scores consistent with the full spectrum of TBI (mild, moderate, and severe), there was a 25% inci- dence of DVT, 6 and up to one-third of moderate to severe TBI patients have been found to suffer DVT. 8 Observation- al studies show that VTC may decrease the incidence of DVT and VTE among patients with TBI without increas- ing the progression of intracranial hemorrhages (ICHs) in those with stable head CT studies and/or neurological examinations. 9,14 The Delayed Versus Early Enoxaparin Prophylaxis I (DEEP-I) randomized control trial found that ICH progression rates among TBI patients with stable ABBREVIATIONS aGCS = admission Glasgow Coma Scale; aRR = adjusted relative risk; AIS = Abbreviated Injury Scale; DVT = deep vein thrombosis; GSW = gunshot wound (to the head); ICH = intracranial hemorrhage; ISS = Injury Severity Score; KAF = Kandahar Airfield; PBI = penetrating brain injury; PE = pulmonary embolism; RR = relative risk; TBI = traumatic brain injury; TXA = tranexamic acid; UFH = unfractionated heparin; USAISR = US Army Institute of Surgical Research; VTC = VTE chemopro- phylaxis; VTE = venous thromboembolism. SUBMITTED January 13, 2016. ACCEPTED April 7, 2016. INCLUDE WHEN CITING Published online June 17, 2016; DOI: 10.3171/2016.4.JNS16101. Early venous thromboembolism chemoprophylaxis in combat-related penetrating brain injury R. Michael Meyer, BS, 1 M. Benjamin Larkin, PharmD, 1 Nicholas S. Szuflita, MPH, 1 Chris J. Neal, MD, 2 Jeffrey M. Tomlin, MD, 2,3 Rocco A. Armonda, MD, 2,4 Jeffrey A. Bailey, MD, 5 and Randy S. Bell, MD 2 1 F. Edward Hébert School of Medicine; 2 Division of Neurosurgery, Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland; 3 Department of Neurosurgery, Naval Medical Center San Diego, California; 4 Department of Neurosurgery, Georgetown University, Washington, DC; and 5 Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland OBJECTIVE Traumatic brain injury (TBI) is independently associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). Given the numerous studies of civilian closed-head injury, the Brain Trauma Foundation recommends venous thromboembolism chemoprophylaxis (VTC) after severe TBI. No studies have specifically examined this practice in penetrating brain injury (PBI). Therefore, the authors examined the safety and effectiveness of early VTC after PBI with respect to worsening intracranial hemorrhage and DVT or PE. METHODS The Kandahar Airfield neurosurgery service managed 908 consults between January 2010 and March 2013. Eighty of these were US active duty members with PBI, 13 of whom were excluded from analysis because they presented with frankly nonsurvivable CNS injury or they died during initial resuscitation. This is a retrospective analysis of the remaining 67 patients. RESULTS Thirty-two patients received early VTC and 35 did not. Mean time to the first dose was 24 hours. Fifty-two patients had blast-related PBI and 15 had gunshot wounds (GSWs) to the head. The incidence of worsened intracranial hemorrhage was 16% after early VTC and 17% when it was not given, with the relative risk approaching 1 (RR = 0.91). The incidence of DVT or PE was 12% after early VTC and 17% when it was not given (RR = 0.73), though this difference was not statistically significant. CONCLUSIONS Early VTC was safe with regard to the progression of intracranial hemorrhage in this cohort of combat- related PBI patients. Data in this study suggest that this intervention may have been effective for the prevention of DVT or PE but not statistically significantly so. More research is needed to clarify the safety and efficacy of this practice. https://thejns.org/doi/abs/10.3171/2016.4.JNS16101 KEY WORDS penetrating brain injury; venous thromboembolism chemoprophylaxis; military neurosurgery; trauma; traumatic brain injury ©AANS, 2017 J Neurosurg Volume 126 • April 2017 1047 Unauthenticated | Downloaded 06/04/20 08:01 AM UTC