Life-Threatening Intracranial Hemorrhage With Unexpectedly High Prothrombin Time Following Venous Thromboembolism Prophylaxis

Hassan Tahir, Adil Wani, Vistasp Daruwalla


Effective thromboprophylaxis with low-dose subcutaneous heparin has been shown to reduce morbidity and mortality. Low-dose prophylactic heparin usually has very low bleeding risk and therefore, prothrombin time (PTT) monitoring or dose adjustment according to age, weight and renal function is not recommended. Life-threatening hemorrhage and markedly elevated PTT with prophylactic heparin is a very rare complication. An 86-year-old woman was admitted with urinary tract infection (UTI) and started on 5,000 U subcutaneous heparin three times a day. Patient condition improved but on day 3, she developed sudden onset of headache, confusion and drowsiness. CT of head showed massive intracranial bleed with midline shift. Craniotomy was done and hematoma was evacuated. PT/INR was normal but PTT was significantly prolonged. Rest of laboratory investigations were inconclusive which ruled out other important causes of elevated PTT and bleeding. Patient was given protamine sulphate and transfused fresh frozen plasma, packed red blood cells and platelets. Patient condition deteriorated and family decided to withdraw life support. Venous thromboembolism (VTE) prophylaxis may be complicated by hemorrhage especially in high risk patients. Heparin should be used cautiously and its effect should be monitored in such patients. Though low-dose unfractioned heparin thrice daily has been found to be superior to twice daily heparin in preventing thromboembolism, bleeding risk is higher.

J Med Cases. 2015;6(7):313-317


Intracranial hemorrhage; Prolonged PTT; Venous thromboembolism; Low molecular weight heparin; Unfractionated heparin; VTE prophylaxis

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