A review of anticoagulation in patients with central nervous system malignancy: between a rock and a hard place

Management of Patients undergoing Elective Craniotomy under Antiplatelet or Anticoagulation Therapy: An International Survey of Practice

BACKGROUND

 The literature concerning the management of antiplatelet (AP) and anticoagulation (AC) medication in the perioperative phase of craniotomy remains scarce. The aim of this international survey was to investigate the current practice among neurosurgeons regarding their perioperative management of AP and AC medication.

METHODS

 We distributed an online survey to neurosurgeons worldwide with questions concerning their perioperative practice with AP and AC medication in patients undergoing craniotomy. Descriptive statistics were performed.

RESULTS

 A total of 130 replies were registered. The majority of responders practice neurosurgery in Europe (79%) or high-income countries (79%). Responders reported in 58.9 and 48.8% to have institutional guidelines for the perioperative management of AP and AC medication. Preoperative interruption time was reported heterogeneously for the different types of AP and AC medication with 40.4% of responders interrupting aspirin (ASA) for 4 to 6 days and 45.7% interrupting clopidogrel for 6 to 8 days. Around half of the responders considered ASA safe to be continued or resumed within 3 days for bypass (55%) or vascular (49%) surgery, but only few for skull base or other tumor craniotomies in general (14 and 26%, respectively). Three quarters of the responders (74%) did not consider AC safe to be continued or resumed early (within 3 days) for any kind of craniotomy. ASA was considered to have the lowest risk of bleeding. Nearly all responders (93%) agreed that more evidence is needed concerning AP and AC management in neurosurgery.

CONCLUSION

 Worldwide, the perioperative management of AP and AC medication is very heterogeneous among neurosurgeons.

A Challenging Case of Metastatic Non-Small Cell Carcinoma of the Lung

Primary lung carcinoma with distant metastasis is a life-threatening diagnosis that presents many unique challenges due to the severity of the disease at the time of presentation. We investigated a life-threatening primary lung carcinoma with distant metastasis in a 73-year-old transgender woman, which posed unique challenges due to the advanced stage of the disease at presentation. The patient exhibited nonspecific musculoskeletal and neurological symptoms resulting from the primary lung carcinoma metastasizing to her liver, bones, and brain. We evaluated various imaging modalities that aided in determining the disease's severity and identifying complications related to metastasis. Although these efforts can offer symptomatic relief, the overall prognosis remains poor when metastasis spreads to multiple organs, particularly the brain, as remission may no longer be attainable.

Cancer and stroke: commonly encountered by clinicians, but little evidence to guide clinical approach

The association between stroke and cancer is well-established. Because of an aging population and longer survival rates, the frequency of synchronous stroke and cancer will become even more common. Different pathophysiologic mechanisms have been proposed how cancer or cancer treatment directly or via coagulation disturbances can mediate stroke. Increased serum levels of D-dimer, fibrin degradation products, and CRP are more often seen in stroke with concomitant cancer, and the clot retrieved during thrombectomy has a more fibrin- and platelet-rich constitution compared with that of atherosclerotic etiology. Multiple infarctions are more common in patients with active cancer compared with those without a cancer diagnosis. New MRI techniques may help in detecting typical patterns seen in the presence of a concomitant cancer. In ischemic stroke patients, a newly published cancer probability score can help clinicians in their decision-making when to suspect an underlying malignancy in a stroke patient and to start cancer-screening studies. Treating stroke patients with synchronous cancer can be a delicate matter. Limited evidence suggests that administration of intravenous thrombolysis appears safe in non-axial intracranial and non-metastatic cancer patients. Endovascular thrombectomy is probably rather safe in these patients, but probably futile in most patients placed on palliative care due to their advanced disease. In this topical review, we discuss the epidemiology, pathophysiology, and prognosis of ischemic and hemorrhagic strokes as well as cerebral venous thrombosis and concomitant cancer. We further summarize the current evidence on acute management and secondary preventive therapy.

Perioperative Complications of Patients with SARS-CoV-2 Infection in Neurosurgery

Background: The outbreak of coronavirus disease 2019 (COVID-19) has been rapidly evolving, resulting in a pandemic, with 270,031,622 infections according to the World Health Organization. Patients suffering from COVID-19 have also been described to suffer from neurologic and coagulopathic symptoms apart from the better-known flu-like symptoms. Some studies showed that patients suffering from COVID-19 were likely to developed intracranial hemorrhages. To our knowledge, only a few studies have investigated postoperative complications in COVID-19-positive neurosurgical patients and investigated the perioperative complications, either thrombotic or hemorrhagic, in patients with SARS-CoV-2 undergoing a neurosurgical intervention. Methods: We conducted a retrospective cohort study including patients from March 2020 to March 2021 undergoing neurosurgical interventions and suffering from COVID-19. Our primary outcome parameter was a hemorrhagic or thrombotic complication within 30 days after surgery. These outcomes were compared to those for a COVID-19-negative cohort of patients using propensity score matching. Results: We included ten COVID-19-positive patients with a mean age of 56.00 (±14.91) years. Twelve postoperative complications occurred in five patients. Three thrombotic complications (30%) were observed, with two cerebral sinus vein thromboses and one pulmonary embolus. Two patients suffered from a postoperative hemorrhagic complication (20%). The mean postoperative GCS was 14.30 (±1.57). COVID-19-positive patients showed a significantly higher rate of overall postoperative complications ((6 (60.0%) vs. 10 (19.2%), p = 0.021), thrombotic complications (3 (30.0%) vs. 1 (1.9%), p = 0.009), and mortality (2 (20.0%) vs. 0 (0.0%), p = 0.021) compared to the matched cohort of COVID-19-negative patients, treated at our institute before the SARS-CoV-2 pandemic. Conclusion: Patients undergoing neurosurgical operations with concomitant COVID-19 infection have higher rates of perioperative complications.