Mind the implementation gap: departure from national guidelines for thromboprophylaxis in traumatic brain injury highlights an urgent need for better evidence

Patients with traumatic brain injury (TBI) are at high risk of experiencing thromboembolic complications. Therefore, the timely initiation of pharmacologic thromboprophylaxis is imperative. However, fear of provoking expansion of intracranial hemorrhage (ICH) has historically led physicians to delay this decision. Recent studies have shown that thromboprophylaxis within 24–72 hours is feasible without increasing the odds of ICH-related complications. National guidelines offer a framework, typically using the modified Berne-Norwood criteria to stratify by risk of ICH expansion and deferring thromboprophylaxis until repeated head CT is stable.1–3 Despite this current evidence and guidelines, the extent to which practice variation persists has remained unclear.