one of the complications of stroke is DVT which brings risk to the patient.

1. Deep Vein
Thrombosis in
Stroke Patients
Ahmed M. Ibrahim

2. Agenda
• Definition
• Epidemiology
• Risk Factors
• Assessment
• Management
• Prophylaxis
• Recommendations

3. Definition
• Deep vein thrombosis (DVT) refers to the formation of one or more blood clots in
one of the body’s large veins, most commonly in the lower limbs (e.g., lower leg
or calf) .
• Deep vein thrombosis (DVT), including pulmonary embolism (PE) as a sequel, is
a serious complication of stroke. It is considered to develop mostly within 2 weeks
post-stroke.

4. Epidemiology
• Deep vein thrombosis (DVT) is a serious complication in stroke patients and may
lead to the devastating consequences of a pulmonary embolism.
• In immobilized post-stroke patients, the incidences of DVTs vary from 10- 75%,
depending on the diagnostic method and time of evaluation.
• Venous thromboembolism (VTE) is also very commonly seen in patients with
subarachnoid hemorrhage (SAH) or an intracerebral hemorrhage (ICH). The risk
of DVT/pulmonary embolism (PE) may even be higher in patients with SAH and
ICH but smallest with the transient ischemic attack (TIA) (Khan et al., 2017).
• The most common cause of mortality from a DVT after a stroke is a PE,
accounting for 13-25% of early deaths, and their incidence usually ranges from 1-
3% in the first few months after a stroke

5. Risk Factors
• The risk factors for DVT in acute stroke are
1. Advanced age
2. High National Institute of Health Stroke Scale (NIHSS) score
3. Hemiparesis
4. Immobility: The incidence of DVT in immobile patients with stroke was between
11% and 15% of patients within the first month of stroke.
5. Dehydration
6. atrial fibrillation
7. Prior history of DVT
8. malignancy and clotting disorders

6. • In Egypt, a study on stroke patients from January to June 2012. 25 out of 280
patients(8.93%) developed DVT during their stay in intensive care unit (ICU) as a
complication of acute stroke. DVT affected mainly the paralyzed limb and was
mainly distal and occurred mostly after 2 weeks of admission. Patients
complicated with DVT were characterized by being older and having higher
percentage of smokers with no impact of gender. Multivariate regression analysis
identified atrial fibrillation (AF) and intracerebral hemorrhage (ICH) as
independent risk factors for early stroke related DVT (p=0.002 & p=0.025
respectively).

7. Assessment: History
• The diagnosis of DVT in the critically ill patients
presents specific challenges because many patients are
not able to communicate their symptoms (such as leg
pain or shortness of breath)
• Throbbing or cramping pain in 1 leg (rarely both legs),
usually in the calf or thigh.

8. Assessment: Examination
• Swelling in one leg (rarely both legs)
• Warm skin around the painful area.
• Red or darkened skin around the painful area.
• Swollen veins that are hard or sore when you touch them.

9. Assessment: Investigations
• The initial test of choice for diagnosing peripheral venous thrombosis is
ultrasound due to its accuracy, low cost, portability, and safety . In addition,
Doppler techniques provide direct information regarding flow physiology.
• Either computed tomography (CT) or magnetic resonance imaging (MRI) can be
used, particularly when studying central veins.
• Other screening tests employed are 125-I fibrinogen scanning and contrast
venography. (Iodine 125-labeled fibrinogen: Radioactive labeled fibrinogen is
given which is incorporated in the thrombus.)

10. Pulmonary Embolism
Common symptoms (>50%)
Dyspnea
Sudden-onset dyspnea
Pleuritic chest pain
Less-common symptoms (16–49%)
Cough †
Lightheadedness/presyncope
Syncope
Leg swelling/pain
Rare symptoms (<15%)
Gradual onset of dyspnea
Orthopnea
Hemoptysis
Angina-like chest pain
Palpitations
Wheezing
Signs
Visible anxiety
Fever
Tachycardia
Tachypnea

11. Management
• Therapeutic anticoagulation is indicated to avoid
pulmonary embolism as it can occur in 50% of patients if
untreated. Untreated acute pulmonary embolism has a 30%
mortality rate, with most deaths occurring within the first
few hours after the initial event due to recurrent pulmonary
embolism.
• Risks associated with anticoagulation include hemorrhagic
transformation of ischemic stroke, hematoma expansion or
recurrent bleeding in patients with intracranial hemorrhage,
or extracranial hemorrhage. These risks must be carefully
weighed against the benefits when considering therapeutic
anticoagulation.

12. • In patients who are not suitable candidates for anticoagulation, inferior vena cava
filter placement is an option.
• For large or severe acute pulmonary embolism in patients unable to receive
anticoagulation, catheter or surgical embolectomy is also a treatment option.

15. Prophylaxis
• Early mobilization is encouraged in patients who can tolerate activity to decrease
the risk of venous thromboembolism.

16. Prophylaxis: Herparin
• The PREvention of VTE [venous thromboembolism] After Acute Ischemic Stroke
With LMWH [low-molecular-weight heparin] Enoxaparin (PREVAIL) study
demonstrated a significantly lower rate of venous thromboembolism without a
significant increase in major hemorrhagic events in patients treated with 40 mg/d
enoxaparin versus 5000 IU unfractionated heparin 2 times a day.

17. Prophylaxis: Elastic Stockings
• CLOTS-1(2009) : These data do not lend support to the use of
thigh-length GCS in patients admitted to hospital with acute
stroke. National guidelines for stroke might need to be revised
on the basis of these results.
• CLOTS-2 (2010) : found fewer cases of VTE with the thigh-
length stockings than below-knee stockings

18. Prophylaxis: Intermittent Pneumatic Compression Devices
• For patients with contraindications for heparin use,
intermittent pneumatic compression devices can be used.
• The use of intermittent pneumatic compression has been
demonstrated to be effective in DVT prevention in
immobilized patients with stroke.
• Contraindications to intermittent pneumatic compression
include peripheral vascular disease causing leg ischemia,
leg ulcerations, dermatitis, and severe leg edema.
CLOTS-3 (2013):
❑ IPC is feasible and safe
❑ IPC is an effective form of VTE prophylaxis NNT = 28 for proximal DVT
❑ It probably improves overall survival NNT~ 43 for death in 30 days
❑ Effective in ischaemic & haemorrhagic stroke

19. Prophylaxis: Aspirin
• Aspirin is also reasonable for DVT prophylaxis in patients who cannot receive
heparin or intermittent pneumatic compression. (Jauch et al., 2013)

20. Prophylaxis
In conclusion, in light of the literature review discussed in this manuscript, we recommend the
following:
• For ischemic stroke, we recommend low-dose anticoagulant therapy, 5,000 units subcutaneously
every eight hours.
• For intracerebral hemorrhage, place SCDs on admission. On Day 2, if the patient is stable,
initiate unfractionated heparin, 5,000 units subcutaneously every eight hours. On Days 10-14, if the
patient is stable, one may switch to chronic oral anticoagulant therapy if there is a high risk (>
7%/yr.) for cardioembolic stroke, with prior deep ICH at low risk (< 1.4%/yr.) for recurrence. On
discharge to a facility: continue until ambulatory.
• In a subarachnoid hemorrhage, on admission place SCDs. On Day 2, if stable, initiate
unfractionated heparin, 5,000 units subcutaneously every eight hours.
*SCDs: pneumatic sequential compression devices

21. • In patients receiving IV rtPA, the initiation of heparin prophylaxis should be
delayed until 24 hours after thrombolytic therapy, and the therapy is recommended
to be continued during the hospitalization or until the patient regains mobility.

23. Spontaneous Intracerebral Hemorrhage : according to AHA Recommendations for Prevention of Deep
Vein Thrombosis and Pulmonary Embolism
• 1. Patients with acute primary ICH and hemiparesis/hemiplegia should have intermittent pneumatic
compression for prevention of venous thromboembolism(Class I, Level of Evidence B).
• 2. After documentation of cessation of bleeding, low-dose subcutaneous low-molecular-weight heparin or
unfractionated heparin may be considered in patients with hemiplegia after 3 to 4 days from onset (Class
IIb, Levelof Evidence B).
• 3. Patients with an ICH who develop an acute proximal venous thrombosis, particularly those with clinical
or subclinical pulmonary emboli, should be considered for acute placement of a vena cava filter (Class IIb,
Level of Evidence C).
• 4. The decision to add long-term antithrombotic therapy several weeks or more after placement of a vena
cava filter must take into consideration the likely cause of the hemorrhage (amyloid [higher risk of
recurrent ICH] versus hypertension), associated conditions with increased arterial thrombotic risk (eg,
atrial fibrillation [AF]), and the overall health and mobility of the patient (Class IIb, Level of Evidence B).

24. Cabrini Score
• The Caprini score is highly recommended to assess the risk of venous thrombosis
in stroke patients. Early mechanical and chemical prophylaxis are recommended
for patients to reduce the incidence of venous thrombosis.

25. Cabrini Score

26. Caprini Score
Risk
category
Recommended prophylaxis**
Duration of
chemoprophylaxis
0 Lowest
Early frequent ambulation only, OR at discretion of
surgical team:
Pneumatic compression devices OR graduated
compression stockings
During hospitalization
1–2 Low
Pneumatic compression devices ± graduated compression
stockings
During hospitalization
3–4 Moderate
Pneumatic compression devices ± graduated compression
stockings
During hospitalization
5–8 High
Pneumatic compression devices AND low dose heparin
OR low molecular weight heparin
7–10 days total
≥9 Highest
Pneumatic compression devices AND low dose heparin
OR low molecular weight heparin
30 days total

27. Thank You