Hemorrhage Rate After External Ventricular Drain Placement in Subarachnoid Hemorrhage: Time to Heparin Administration.

Abstract

The use of antiplatelet or anticoagulants has previously been shown to increase hemorrhagic complications of ventricular catheterization. Although heparin use 24h after ventriculostomy appears safe, the safety of heparin immediately (within 4h) after ventriculostomy is unknown. The objective of this study was to assess the safety of heparin immediately (within 4h) after ventriculostomy in subarachnoid hemorrhage (SAH) patients undergoing endovascular treatment. This is a retrospective cohort study of 46 patients with aneurysmal SAH secondary to aneurysm rupture who required ventriculostomy. Post-ventriculostomy imaging was carefully reviewed for tract hemorrhaging. Timing of heparinization was noted. Early heparinization was within 4h after ventriculostomy, and intermediate heparinization was between 4 and 24h after ventriculostomy. Overall, the tract hemorrhage rate was 26.1% for the study cohort-mostly grade I tract hemorrhages-consistent with the existing literature. The tract hemorrhage rate in the early (<4h) heparin group was a remarkable 58.8%. The hemorrhages were also notably larger in the early (<4h) heparin group. Although heparin appears to be safe after 4h, immediate heparinization (within 4h) after ventriculostomy significantly increases the odds of tract hemorrhage. Additional time should be afforded between ventriculostomy and heparinization to avoid potentially devastating external ventricular drain tract hemorrhage. It is advisable to wait a sufficient time (at least 4h) after ventriculostomy before embarking on endovascular treatment of ruptured aneurysms.