This document discusses the role of anticoagulation in neurocritical care. It notes that patients with neurological diseases or injuries have a high risk of developing blood clots. While pharmacological thromboprophylaxis can reduce the risk of clots compared to mechanical prophylaxis alone, anticoagulants should only be started after bleeding risks decrease in conditions like stroke, brain hemorrhage, or trauma. The document reviews guidelines for use of anticoagulants in different conditions and compares options like heparin, low molecular weight heparin, and newer oral anticoagulants. It emphasizes tailoring anticoagulation decisions based on individual patient risks and bleeding risks.

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

2. Goals of Talk
• Role of Anticoagulation as a DVT prophylaxis
in various Neurological disease
• Role of Anticoagulation in Ischemic Stroke and
Cerebral Venous Thrombosis
• When to start Anticoagulants in various
Neurosurgical conditions
• Newer Oral Anticoagulant

3. • Patients with Neurologic disease or a
neurosurgical conditions, have very high risk of
VTE.
• DVTs may be present in 15-40% of all hospitalised
neurosurgical patients, 40-60% of head trauma
patients and 20-40% of hospitalised stroke
patients
• Thus, awareness to prevent the DVT and its
complications is very important Neurologic Critical Care
March 2017, Volume 45, No. 3

4. • 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
Neurologic Critical Care
March 2017, Volume 45, No. 3

5. • Any patients who are immobilised for more
than 48 hours are candidates for DVT
prophylaxis
ACCP 2012 guideline

6. Parenteral Anticoagulants
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
Monitoring aPTT No No
Advantage of UFH over LMWH is safe in Renal failure and
shorter duration of action

7. Prophylactic dose
• UFH – 5000 Unit SC bid/tid
• Enoxaparin
- 40 mg SC od
- If 1) Cr CL < 30 ml/min
2) 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

8. 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 od
- If CrCl < 30 ml/min - 1 mg/kg SC od
LMWH IS PREFERRED OVER UFH
Dalteparin and Fondaparinux is not
recommended.

9. Ischemic stroke
DVT Prophylaxis
• In patients with Acute Ischemic Stroke with
restricted mobility combined, Pharmacological
and Mechanical Prophylaxis is indicated
• LMWH is preferred over UFH
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. Ischemic Stroke
• In thrombolysed patients, Pharmacological
prophylaxis for DVT should be delayed upto 24
hours
• After thrombolysis, therapeutic
Anticoagulation should not be used
AHA Guideline 2018;49 eXXX-eXXX
Management of Acute Ischemic Stroke

13. 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
• Initially UFH is safe
Curr Opin Crit Care 2016 22:113-119

14. ICH/SAH/TBI
• Pharmacological DVT prophylaxis can be
started after 48 hours of documented
stoppage of bleeding and discussion with
Neurosurgeon

15. 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

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

17. 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

18. 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 parenteral
anticoagulants

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

20. When to start Oral Anticoagulation
after ICH in patient with AF?
• Can be started after 7-10 days of documented
stoppage of bleeding
• But decision should be based on case to case
basis and risk benefit ratio
• Compare the risk of Anticoagulation related
ICH and risk of thromboembolic events
without Anticoagulants

21. Risk Factors

22. Conclusion
• VTE is a major cause of sudden death in
Neurocritical care
• LMWH should be used as a DVT prophylaxis,
rather than mechanical prophylaxis
• Therapeutic (full dose) Anticoagulation should
not be used in all patients of Ischemic Stroke
as it increase the risk of ICH
• In Post surgical and ICH patients DVT
prophylaxis
• Non valvular AF patients NOAC is preferred
over warfarin

23. THANK YOU