Therapeutic Anticoagulation in Patients with Traumatic Brain Injuries and Pulmonary Emboli.

BACKGROUND Patients with traumatic intracranial hemorrhage (ICH) and concomitant pulmonary embolus (PE) have competing care needs and demand a careful balance of anticoagulation (AC) versus potential worsening of their ICH. The goal of this study is to determine the safety of therapeutic AC for PE in patients with ICH. METHODS This is a retrospective single center study of patients >16 years old with concomitant ICH and PE occurring between June 2013 and December 2017. Early AC was defined as within ≤7 days of injury; late was defined as after 7 days. Primary outcomes included death, interventions for worsening ICH following AC, and pulmonary complications. Multivariate logistic regression was used to evaluate for clinical and demographic factors associated with worsening TBI, and recursive partitioning was used to differentiate risk in groups. RESULTS Fifty patients met criteria. Four did not receive any AC and were excluded. Nineteen (41.3%) received AC early (median 4.1, IQR 3.1-6) and 27 (58.7%) received AC late (median 14, IQR 9.7-19.5). There were four deaths in the early group, and none in the late cohort (21.1% vs. 0%, p=0.01). Two deaths were due to PE and the others were from multi-system organ failure or unrecoverable underlying TBI. Three patients in the early group, and two in the late, had increased ICH on CT (17.6% vs. 7.4%, p=0.3). None required intervention. CONCLUSIONS This retrospective study failed to find instances of clinically significant progression of TBI in 46 patients with CT-proven ICH after undergoing AC for PE. Therapeutic AC is not associated with worse outcomes in patients with TBI, even if initiated early. However, two patients died from PE despite AC, underlining the severity of the disease. ICH should not preclude AC treatment for PE, even early after injury. STUDY TYPE care management LEVEL OF EVIDENCE: level III.