Patients with traumatic brain injury (TBI) or spinal cord injury (SCI) have an increased risk of venous thromboembolism (VTE). The reported incidence of VTE in studies of TBI and SCI patients varies widely from 1-54% depending on factors like injury severity and use of prophylaxis. The true incidence is difficult to determine due to limitations of studies and many cases being asymptomatic. VTE risk is highest in the acute phase after injury.

1. Incidence and risk factors between
TBI/SCI and venous
thromboembolism
Dr Amit Agrawal, MCh
Department of Neurosurgery
Narayana Medical College and Hospital
Chintareddypalem, Nellore (AP), India

2.  Conflict of interest: None

3. Risk Factors High Risk Factors Very High Risk Factors
• Age > 40 years
• ISS > 9
• Blood transfusions
• Surgical procedure
within 72 hrs
• Immobilization
• Malignancy
• Extensive soft tissue
trauma
• Hormone therapy
• Obesity
• AIS ≥ 3 (any region)
 Age > 60 years
 ISS > 15
 GCS < 9 for > 4 hours
 Major venous
injury/repair
 PMH of venous
thromboembolism
(VTE)
 Lower extremity
fracture
 Multiple spinal
fractures
 Pregnancy
 Spinal cord injury with
paraplegia or
quadriplegia
 Complex or multiple
(≥ 2) lower extremity
fractures
 Major pelvic fracture
 Multiple (≥ 3) long
bone fractures (≥ 1 in
the lower extremity)
 Age ≥ 75 years with
any high risk factor
Risk factors
Yablon SA, et al. Deep vein thrombosis: prevalence and risk factors in rehabilitation
admissions with brain injury. Neurology. 2004 10;63(3):485-91.
Ekeh AP, et al. Incidence and risk factors for deep venous thrombosis after moderate
and severe brain injury. J Trauma. 2010 ;68(4):912-5.

4.  Patients with TBI/SCI are at increased risk of venous
thromboembolic events (VTE)
Risk factors

5. Risk Assessment Profile (RAP Score)
Greenfield et al. Posttrauma thromboembolism prophylaxis. J Trauma. 1997 ;42(1):100-3.

6.  Deep venous thrombosis (DVT) has an incidence that varied
between 40 and 54% without prophylaxis in the context of
severe traumatic brain injury
 In different population studies in different parts of the world
have reported an incidence ranging from 5 to 10%
 Pulmonary embolism varied between 1 and 6%
TBI: Incidence
Phelan HA. Venous thromboembolism after traumatic brain injury. Semin Thromb Hemost 2013;39:541-8.
Phelan HA. Pharmacologic venous thromboembolism prophylaxis after traumatic brain injury: a critical literature review. J Neurotrauma 2012;29:1821-8
Denson et al. Incidence of venous thromboembolism in patients with traumatic brain injury. Am J Surg 2007;193:380-4.
Bahloul M et al. Pulmonary embolism following severe traumatic brain injury: incidence, risk factors and impact outcome. Intensive Care Med
2017;43:1433-5.
Praeger AJ, et al. Deep vein thrombosis and pulmonary embolus in patients with traumatic brain injury: a prospective observational study. Crit Care
Resusc 2012;14:10-3.
Khaldi A, Helo N, Schneck MJ, Origitano TC. Venous thromboembolism: deep venous thrombosis and pulmonary embolism in a neurosurgical
population. J Neurosurg 2011;114:40-6.
Skrifvars MB, Bailey M, Presneill J, French C, Nichol A, Little L, et al. investigators and the ANZICS Clinical Trials Group. Venous thromboembolic events in
critically ill traumatic brain injury patients. Intensive Care Med

7. VTE PE DVT
Abdel-Aziz H et al. 2.8% in over 4000 cases
Denson et al.
Bahloul M et al.
Praeger et al.
0.3 to 17%
Bradley et al. 2.58%
Geerts WH et al. 25%
Dengler BA et al. 12%
Eppsteiner et al. 20%
Denson K et al. 25%
TBI: Incidence
Abdel-Aziz H et al. Timing for deep vein thrombosis chemoprophylaxis in traumatic brain injury: an evidence-based review. Crit Care 19:96
Denson et al. Incidence of venous thromboembolism in patients with traumatic brain injury. Am J Surg 2007;193:380-4.
Bahloul M et al. Pulmonary embolism following severe traumatic brain injury: incidence, risk factors and impact outcome. Intensive Care Med 2017;43:1433-5.
Praeger et al. Deep vein thrombosis and pulmonary embolus in patients with traumatic brain injury: a prospective observational study. Crit Care Resusc 2012;14:10-3
Ali Seifi Bradley Dengler, Paola Martinez, Daniel Agustin Godoy. Pulmonary embolism in severe traumatic brain injury
Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. N Eng J Med 1994;331:1601-6.
Dengler BA, Mendez-Gomez P, Chavez A, Avila L, MichalekJ, Hernandez B, et al. Safety of chemical DVT prophylaxis in severe traumatic brain injury with invasive monitoring devices. Neurocrit Care
2016;25:215-23.
Eppsteiner et al. Mechanical compression versus subcutaneous heparin therapy in postoperative and posttrauma patients: a systematic review and meta-analysis. World J Surg;34(1):10-9
Denson K, Morgan D, Cunningham R, et al. Incidence of venous thromboembolism in patients with traumatic brain injury. Am J Surg. 2007;193:380-383; discussion 383-384.

8.  Acute spinal cord injury (SCI) have the highest incidence of
venous thromboembolism (VTE) among hospitalized patients*
 Pulmonary embolism (PE) is the third most common cause of
mortality in patients with SCI (incidence as high as 5%)**
 DVT does occur past the 3rd month, usually up to the 6th
month***
SCI: Incidence
*Paciaroni M, Ageno W, Agnelli G. Prevention of venous thromboembolism after acute spinal cord injury with low-dose heparin or low-molecular-weight heparin. Thromb
Haemost. 2008; 99(5): 978-80.
*Worley S, Short C, Pike J, et al. Dalteparin vs low-dose unfractionated heparin for prophylaxis against clinically evident venous thromboembolism in acute traumatic spinal cord
injury: a retrospective cohort study. J Spinal Cord Med. 2008; 31(4): 379-87.
**Teasell RW, Hsieh JT, Aubut JA, et al. Venous thromboembolism after spinal cord injury. Arch Phys Med Rehabil. 2009; 90(2): 232-45.
***Caprini JA. Risk assessment as a guide to thrombosis prophylaxis. Curr Opin Pulm Med 2010;16(5):448-52.
****Powell M et al. Duplex Ultrasound screening for deep vein thrombosis in spinal cord injured patients at rehabilitation admission. Arch Phys Med Rehabil 1999;80(9): 1044-6.
****Chen et al. Medical complications during acute rehabilitation following spinal cord injury—current experience of the model systems. Arch Phys Med Rehabil 1999;
80(11):1397-401.
*****Green et al. Prevention of thromboembolism in spinal cord injury; role of low molecular weight heparin. Arch Phys Med Rehabil 1994;75(3): 290-2.
******Yelnik A et al. Systematic lower limb phlebography in acute spinal cord injury in 147 patients. Paraplegia 1991;29(4): 253-60.

9.  Paraplegic patients more frequently than in tetraplegic
ones****
 Tetraplegic patients more frequently than in paraplegic
ones*****
 No difference between patients with paraplegia and
tetraplegia******
SCI: Incidence
*Paciaroni M, Ageno W, Agnelli G. Prevention of venous thromboembolism after acute spinal cord injury with low-dose heparin or low-molecular-weight heparin. Thromb
Haemost. 2008; 99(5): 978-80.
*Worley S, Short C, Pike J, et al. Dalteparin vs low-dose unfractionated heparin for prophylaxis against clinically evident venous thromboembolism in acute traumatic spinal cord
injury: a retrospective cohort study. J Spinal Cord Med. 2008; 31(4): 379-87.
**Teasell RW, Hsieh JT, Aubut JA, et al. Venous thromboembolism after spinal cord injury. Arch Phys Med Rehabil. 2009; 90(2): 232-45.
***Caprini JA. Risk assessment as a guide to thrombosis prophylaxis. Curr Opin Pulm Med 2010;16(5):448-52.
****Powell M et al. Duplex Ultrasound screening for deep vein thrombosis in spinal cord injured patients at rehabilitation admission. Arch Phys Med Rehabil 1999;80(9): 1044-6.
****Chen et al. Medical complications during acute rehabilitation following spinal cord injury—current experience of the model systems. Arch Phys Med Rehabil 1999;
80(11):1397-401.
*****Green et al. Prevention of thromboembolism in spinal cord injury; role of low molecular weight heparin. Arch Phys Med Rehabil 1994;75(3): 290-2.
******Yelnik A et al. Systematic lower limb phlebography in acute spinal cord injury in 147 patients. Paraplegia 1991;29(4): 253-60.

10.  Acute phase*
 5.3-64% when prophylaxis is implemented
 47 to 100% when no prophylactic measures
SCI: Incidence Acute Phase
*Jones T, Ugalde V, Franks P, Zhou H, White RH. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in
16,240 adults and children. Arch Phys Med Rehabil 2005;86(12):2240-7.
*Furlan JC, Fehlings MG. Role of screening tests for deep venous thrombosis in asymptomatic adults with acute spinal cord injury: an evidence-based
analysis. Spine 2007;32(17):1908-16.
*Teasell RW, Hsieh JT, Aubut JA, Eng JJ, Krassioukov A, Tu L. Venous thromboembolism after spinal cord injury. Arch Phys Med Rehabil 2009;90(2):232-
45.
*Geerts WH, Code KI, Jay RM, Chen E, Szalai JP. A prospective study of venous thromboembolism after major trauma. New Engl J Med
1994;331(24):1601-6.
*Boudaoud L, Roussi J, Lortat-Jacob S, Bussel B, Dizien O, Drouet L. Endothelial fibrinolytic reactivity and the risk of deep venous thrombosis after spinal
cord injury. Spinal Cord 1997; 35(3):151-7.
*Powell M, Kirshblum S, O’Connor CK. Duplex Ultrasound screening for deep vein thrombosis in spinal cord injured patients at rehabilitation admission.
Arch Phys Med Rehabil 1999;80(9): 1044-6.

11.  Less and incosistent data on the actual risk during the sub-acute
phase *
 The 3rd to the 12th month in 8-12% **
 At three months, at six months, and at one year: 34%, 1.1%, and
0.4%, respectively***
 Three and six months after the trauma: ranged from 0.5% to
6.0% and from 2.0% to 8.0%, respectively****
SCI: Incidence in sub-acute and chronic
phase
*Jones Tet al. Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children. Arch
Phys Med Rehabil 2005; 86: 2240-7.
*Giorgi et al. The short- and long-term risk of venous thromboembolism in patients with acute spinal cord injury: a prospective cohort study. Thromb
Haemost 2013; 109: 34-8.
**Furlan et al. Role of screening tests for deep venous thrombosis in asymptomatic adults with acute spinal cord injury: an evidence-based analysis.
Spine 2007;32(17):1908-16.
**Boudaoud et al. Endothelial fibrinolytic reactivity and the risk of deep venous thrombosis after spinal cord injury. Spinal Cord 1997; 35(3):151-7.
**Mackiewicz-Milewska et al. Deep venous thrombosis in patients with chronic spinal cord injury
***Green et al. Spinal Cord Injury Assessment for Thromboembolism (SPI- RATE Study). Am J Phys Med Rehabil 2003; 82: 950-956.
****Alabed et al. Thromboembolism in the sub-acute phase of spinal cord injury: A systematic review of the literature. Asian Spine J 2016; 10: 972-981.

12.  The lack of large-scale population prevalence studies
 The majority of cases are asymptomatic or subclinical and go
unnoticed or difficult to diagnose
 Can be confused with many other entities
True incidence??
Donald A et al. Traumatic Brain Injury Is Associated With the Development of Deep Vein Thrombosis Independent of Pharmacological
Prophylaxis. J Trauma. 2009;66:1436-1440.
Phelan HA. Venous thromboembolism after traumatic brain injury. Semin Thromb Hemost 2013;39:541-8.
Nyquist P, et al. Prophylaxis of venous thrombosis in neurocritical care patients: an evidence- based guideline: a statement for healthcare
professionals from the neurocritical care society. Neurocrit Care 2016;24:47-60.
Denson K, et al. Incidence of venous thromboembolism in patients with traumatic brain injury. Am J Surg 2007;193:380-4.
Bahloul M, et al. Pulmonary embolism following severe traumatic brain injury: incidence, risk factors and impact outcome. Intensive Care
Med 2017;43:1433-5.
Praeger AJ, et al. Deep vein thrombosis and pulmonary embolus in patients with traumatic brain injury: a prospective observational study.
Crit Care Resusc 2012;14:10-3

13.  Most of the studies are heterogeneous in populations, design
and outcome reporting
 Studies have limitations inherent to the methodology and
diagnostic tools employed

True incidence??
Donald A et al. Traumatic Brain Injury Is Associated With the Development of Deep Vein Thrombosis Independent of Pharmacological
Prophylaxis. J Trauma. 2009;66:1436-1440.
Phelan HA. Venous thromboembolism after traumatic brain injury. Semin Thromb Hemost 2013;39:541-8.
Nyquist P, et al. Prophylaxis of venous thrombosis in neurocritical care patients: an evidence- based guideline: a statement for healthcare
professionals from the neurocritical care society. Neurocrit Care 2016;24:47-60.
Denson K, et al. Incidence of venous thromboembolism in patients with traumatic brain injury. Am J Surg 2007;193:380-4.
Bahloul M, et al. Pulmonary embolism following severe traumatic brain injury: incidence, risk factors and impact outcome. Intensive Care
Med 2017;43:1433-5.
Praeger AJ, et al. Deep vein thrombosis and pulmonary embolus in patients with traumatic brain injury: a prospective observational study.
Crit Care Resusc 2012;14:10-3