This document discusses the role of anticoagulation in neurocritical care. It notes that anticoagulation remains the mainstay for preventing and treating thrombosis. It then compares different anticoagulants and their properties. It provides dosing guidelines for prophylactic and therapeutic anticoagulation in various neurologic conditions and procedures. Finally, it discusses newer oral anticoagulants and their advantages over warfarin, though they lack reversal agents and are not useful in renal failure or pregnancy.

1. Role of Anticoagulation in
Neurocritical Care
DR Ankit Gajjar
MD, Anesthesia, IDCCM, IFCCM, EDIC
Consultant Intensivist at INS Hospital

2. • Anticoagulation remains the main stay of
treatment for prevention and treatment of
thrombosis
• Aim of our lecture is to clear point about role
of anticoagulation in neurocritical care

3. Comparison
Features Heparin LMWH Fondaperinux
Target Xa=IIa Xa > iia Xa
Bioavailability 30 90 100
Half life (hr) 1 4 17
Renal Clearance No Yes Yes
Protamine reversal Complete Partial None
HIT < 5% <1% Case Reports
Advantage of UFH over LMWH is safe in Renal failure and
shorter duration of action

4. Prophylactic dose
• UFH – 5000 Unit SC bid/tid
• Enoxaparin
- 40 mg SC od
- If Cr CL < 30 ml/min,
Age > 75 years – 30 mg SC od
• Dalteparin 2500 units or 5000 units sc od
• Fondaparinux – 2.5 mg SC od
• LMWH IS PREFERRED OVER UFH

5. Therapeutic dose
• UFH – 80 U/kg bolus f/b 18 U/kg/hr
- Target aPTT 1.5 – 2 times normal (60 to 80
secs)
• Enoxaparin – 1 mg/kg SC bid or 1.5 mg/kg SC bid
- If CrCl<30 ml/min 1 mg/kg SC od
LMWH IS PREFERRED OVER UFH
Dalteparin and Fondaparinux is not
recommended.

6. • Patients with Neurologic disease or those
undergoing procedure for a neurologic or a
neurosurgical conditions, have very high risk of
VTE.
• DVTs may be present in 15-40% of all hospitalised
neurosurgical patients, 40-80% of head trauma
patients and 20-40% of hospitalised stroke
patients
• Thus, awareness of this risk is critical to prevent
the DVT and its complications.

7. • Among Neuro patients treated with
Mechanical Prophylaxis alone, DVTs rate is as
high as 32%
• Pharmacological thromboprophylaxis
associated with further 50% reduction in risk
of DVT

8. • Any patients who are immobilised for more
than 48 hours are candidates for DVT
prophylaxis

9. Ischemic stroke
• In patients with Acute Ischemic Stroke with
restricted mobility combined, Pharmacological
and Mechanical Prophylaxis
• In thrombolysed patients, should be delayed
upto 24 hours
Neurologic Critical Care
March 2017, Volume 45, No. 3

10. Ischemic Stroke
• Therapeutic anticoagulation
1) Cardio embolic stroke except large infarct
2) Spontaneous cerebral and cervical artery
dissection
3) Progressive or recurrent stroke despite of
antiplatelet therapy

11. Ischemic Stroke
• Early aggressive treatment with therapeutic
anticoagulation in other types of ischemic
stroke worsen the mortality by increasing risk
of intracranial haemorrhage
• Anticoagulant should be used as a DVT
prophylaxis
AHA Guideline 2018;49 eXXX-eXXX
Management of Acute Ischemic Stroke

12. Cerebral Venous Thrombosis
• Earliest to start Therapeutic Anticoagulation
• LMWH is preferred over UFH
• Presence of haemorrhagic venous infarct is
not a contraindication
• After Decompressive Hemicraniectomy,
Anticoagulant can be safely started within 24
hours
Curr Opin Crit Care 2016 22:113-119

13. ICH/SAH/TBI
• Can be started after 48 hours of documented
stoppage of bleeding
• Again combined prophylaxis is indicated

14. Post Surgical
• Can be start after 24 hours of Post
Craniotomy, if bleeding risk is not high
• Initially UFH is preferred over LMWH due to
ease of reversibility and shorter duration of
action

15. • Neuromuscular disease like GBS, Myasthenia
Gravis etc LMWH is indicated as a VTE is a
major risk factor for sudden death

16. Newer Oral Anticoagulants
Features Dabigatran Rivaroxaban Epixaban
Target Thrombin Factor Xa Factor Xa
Bioavailability (%) 6 80 90
Half life (h) 12-17 5-9 12
Onset of action 1-3 hr 2-4 hr 1-2 hr
Renal excretion 80 65 25
Coagulation
monitoring
No No No
Antidote Idarucizumab
(Praxbind)
No No
Dosage
Cr cl > 50 ml/min
15-50 ml/min
150 mg PO bd
75 mg PO bd
20 mg PO od with food
15 mg PO od
5 mg PO bd
2.5 mg PO bd
Monitoring Reversal Thrombin time Anti Xa level

17. Newer Oral Anticoagulants
• Advantage
• More effective than warfarin in prevention of
ischemic stroke in patients with non valvular AF
• No need of dietary restriction
• Less drug drug interaction
• Quick onset and offset of action
• No need of monitoring or dose titration
• No need of overlapping with parentral
anticoagulants

18. Newer Oral Anticoagulants
• Disadvantage
• No reversal agent
• Costly
• Not useful in renal failure and pregnancy