Coagulation Management in Neurosurgical Critical Care

  • Irene Dehghan-PazEmail author
  • Thomas P. Bleck
  • Sarice L. Bassin


Neurocritical care patients are at extremely high risk for complications related to hereditary or acquired coagulopathies, as well as venous thromboembolic complications. The benefits of pharmacologic prevention and treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) must be weighed against the risk of catastrophic intracranial or perispinal hemorrhage. This section focuses on the two most common coagulation management issues: (1) thromboembolic disease and (2) coagulopathy.


Thromboembolic disease Coagulopathy Disseminated intravascular coagulation Pulmonary ventilation flow scan Critical care 

Suggested Reading

  1. ACTIVE Investigators, Connolly SJ, Pogue J, Hart RG, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360:2066–78.CrossRefGoogle Scholar
  2. Agnelli G, Piovella F, Buoncristiani P, et al. Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery. N Engl J Med. 1998;339:80–5.CrossRefGoogle Scholar
  3. Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Acute pulmonary embolectomy: a contemporary approach. Circulation. 2002;105(12):1416–9.CrossRefGoogle Scholar
  4. Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonist. Chest. 2008;133:160S–98.CrossRefGoogle Scholar
  5. Chatterjee S, Sardar P, Biondi-Zoccai G, Kumbhani DJ. New oral anticoagulants and the risk of intracranial hemorrhage: traditional and Bayesian meta-analysis and mixed treatment comparison of randomized trials of new oral anticoagulants in atrial fibrillation. JAMA Neurol. 2013;70:1486–90.PubMedGoogle Scholar
  6. Crowther MA, Cook DJ, Griffith LE, et al. Neither baseline tests of molecular hypercoagulability nor D-dimer levels predict deep venous thrombosis in critically ill medical-surgical patients. Intensive Care Med. 2005;31:48–55.CrossRefGoogle Scholar
  7. De Manoel O, et al. The critical care management of spontaneous intracranial hemorrhage: a contemporary review. Crit Care. 2016;20:272.CrossRefGoogle Scholar
  8. De Monyé W, Sanson BJ, Mac Gillavry MR, et al. Embolus location affects the sensitivity of a rapid quantitative D-dimer assay in the diagnosis of pulmonary embolism. Am J Respir Crit Care Med. 2002;165:345–8.CrossRefGoogle Scholar
  9. Droubatchevskaia N, Wong WP, Chipperfield KM, Wadsworth LD, Ferguson DJ. Guidelines for cryoprecipitate transfusion.Google Scholar
  10. Frontera, et al. Guideline for reversal of antithrombotics in intracranial hemorrhage; a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit Care. 2016;24:6–46.CrossRefGoogle Scholar
  11. Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med. 1996;335:701–7.CrossRefGoogle Scholar
  12. Goldstein JN, Greenberg SM. Should anticoagulation be resumed after intracerebral hemorrhage? Cleve Clin J Med. 2010;77(11):791–9.CrossRefGoogle Scholar
  13. Grove JR, Pevec WC. Venous thrombosis related to peripherally inserted central catheters. J Vasc Interv Radiol. 2000;11:837–40.CrossRefGoogle Scholar
  14. Guyatt GH, Akl EA, Crowther M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):7S–47S.CrossRefGoogle Scholar
  15. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–29.CrossRefGoogle Scholar
  16. Hamilton MG, Hull RD, Pineo GF. Venous thromboembolism in neurosurgery and neurology patients: a review. Neurosurgery. 1994;34:280–96.CrossRefGoogle Scholar
  17. Hart RG, Tonarelli SB, Pearce LA. Avoiding central nervous system bleeding during antithrombotic therapy: recent data and ideas. Stroke. 2005;36:1588–93.CrossRefGoogle Scholar
  18. Irem Baharoglu M, Cordonnier C, Al-Shahi Salman R, de Gans K, Koopman MM, Brand A, Majoie CB, Beenen LF, Marquering HA, Vermeulen M, Nederkoorn PJ, de Haan RJ, Roos YB. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387:2605–13.CrossRefGoogle Scholar
  19. Joffe HV, Kucher N, Tapson V, et al. Upper-extremity deep vein thrombosis a prospective registry of 592 patients. Circulation. 2004;110:1605–11.CrossRefGoogle Scholar
  20. Karafin MS, Hilyer CD, Shaz BH. Principles of plasma transfusion: plasma, cryoprecipitate, albumin, and immunoglobulins. In: Hoffman R, Benz EJ, Silberstein LE, Heslop H, Weltz J, Anstasi J, editors. Hematology: diagnosis and treatment. Philadelphia: Elsevier; 2012. p. 1683–94.Google Scholar
  21. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419S–96S.CrossRefGoogle Scholar
  22. Kim J, Gearhart MM, Zurick A, et al. Preliminary report on the safety of heparin for deep venous thrombosis prophylaxis after severe head injury. J Trauma. 2002;53:38–43.CrossRefGoogle Scholar
  23. Levi M, Cromheecke ME, de Jonge E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet. 1999;354:1940–7.CrossRefGoogle Scholar
  24. Liumbruno GM, Bennardello F, Lattanzio A, et al. Recommendations for the transfusion management of patients in the peri-operative period. I. The pre-operative period. Blood Transfus. 2011;9:19–40.PubMedPubMedCentralGoogle Scholar
  25. Mahdy AM, Webster NR. Perioperative systemic haemostatic agents. Br J Anaesth. 2004;93:842–588.CrossRefGoogle Scholar
  26. Mannucci PM. Hemostatic drugs. N Engl J Med. 1998;339:245–53.CrossRefGoogle Scholar
  27. Mannucci PM. Intracerebral haemorrhage and recombinant factor VIIa: not so good news! Intern Emerg Med. 2007;2:235–6.CrossRefGoogle Scholar
  28. Mannucci PM, Ghirardini A. Desmopressin: twenty years after. Thromb Haemost. 1997;78:958.CrossRefGoogle Scholar
  29. Nelson MD, Maeder MA, Usner D, et al. Prevalence and incidence of intracranial hemorrhage in a population of children with haemophilia. The hemophilia growth and development study. Haemophilia. 1999;5:306–12.CrossRefGoogle Scholar
  30. Norwood SH, McAuley CE, Berne JD, et al. Prospective evaluation of the safety of enoxaparin prophylaxis for venous thromboembolism in patients with intracranial hemorrhagic injuries. Arch Surg. 2002;137:696–702.CrossRefGoogle Scholar
  31. Pantanowitz L, Kruskall MS, Uhl L. Cryoprecipitate patterns of use. Am J Clin Pathol. 2003;119:874–81.CrossRefGoogle Scholar
  32. Praxbind®. Ridgefield: Boehringer Ingelheim Pharmaceuticals; 2015.
  33. Qureshi AI, Suri MFK. Acute reversal of clopidogrel-related platelet inhibition using methyl prednisolone in a patient with intracranial hemorrhage. Am J Neuroradiol. 2008;29:e97.CrossRefGoogle Scholar
  34. Raj G, Kumar R, McKinney WP. Time course of reversal of anticoagulant effect of warfarin by intravenous and subcutaneous phytonadione. Arch Intern Med. 1999;159:2721–4.CrossRefGoogle Scholar
  35. Rathbun SW, Whitsett TL, Vesely SK, Raskob GE. Clinical utility of D-dimer in patients with suspected pulmonary embolism and nondiagnostic lung scans or negative CT findings. Chest. 2004;125:851–5.CrossRefGoogle Scholar
  36. Righini M, Le Gal G, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet. 2008;371:1343–52.CrossRefGoogle Scholar
  37. Sachdeva A1, Dalton M, Amaragiri SV, Lees T. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2010;7:CD001484.Google Scholar
  38. Schaefer JK, McBane RD, Wysokinski WE. How to choose appropriate direct oral anticoagulant for patient with nonvalvular atrial fibrillation. Ann Hematol. 2016;95:437–49.CrossRefGoogle Scholar
  39. Schroder WS, Gandhi PJ. Emergency management of hemorrhagic complications in the era of glycoprotein IIb/IIIa receptor antagonist, clopidogrel, low molecular weight heparin, and third-generation fibrinolytic agents. Curr Cardiol Rep. 2003;5:310–7.CrossRefGoogle Scholar
  40. Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23–32.CrossRefGoogle Scholar
  41. Siegal D, Cuker A. Reversal of novel oral anticoagulants in patients with major bleeding. J Thromb Thrombolysis. 2013;35:391–8.CrossRefGoogle Scholar
  42. Stainsby D, MacLennan S, Hamilton PJ. Management of massive blood loss: a template guideline. Br J Anaesth. 2000;85:487–91.CrossRefGoogle Scholar
  43. Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med. 2004;140:589–602.CrossRefGoogle Scholar
  44. Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. Am J Med. 2007a;120:871–9.CrossRefGoogle Scholar
  45. Stein PD, Alnas M, Beemath A, Patel NR. Outcome of pulmonary embolectomy. Am J Cardiol. 2007b;99:421–3.CrossRefGoogle Scholar
  46. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–7.CrossRefGoogle Scholar
  47. van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295:172–9.CrossRefGoogle Scholar
  48. Van Berkel MA, Crannage AJ, Murphy JA. Evaluation of education on the appropriate use of vitamin k in warfarin reversal in adult inpatients. Hosp Pharm. 2013;48(8):662–7.CrossRefGoogle Scholar
  49. van Rossum AB, van Houwelingen HC, Kieft GJ, Pattynama PM. Prevalence of deep vein thrombosis in suspected and proven pulmonary embolism: a meta-analysis. Br J Radiol. 1998;71:1260–5.CrossRefGoogle Scholar
  50. Van Ryn J, Stangier J, Haertter S, Liesenfeld KH, Wienen W, Feuring M, Clemens A. Dabigatran etexilate – a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost. 2010;103(6):1116–27.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Irene Dehghan-Paz
    • 1
    Email author
  • Thomas P. Bleck
    • 2
  • Sarice L. Bassin
    • 3
  1. 1.Department of Internal Medicine, Section of HematologyRush University Medical CenterChicagoUSA
  2. 2.Division of Stroke and Neurocritical CareNorthwestern University Feinberg School of MedicineChicagoUSA
  3. 3.PeaceHealth Southwest Medical CenterVancouverUSA

Personalised recommendations