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Orban C, Abramovic A, Gmeiner R, Lener S, Demetz M, Thomé C. The Influence of Preoperative Anticoagulant and Antiplatelet Therapy on Rebleeding Rates in Patients Suffering from Spinal Metastatic Cancer: A Retrospective Cohort Study. Cancers (Basel) 2024; 16:2052. [PMID: 38893171 PMCID: PMC11171320 DOI: 10.3390/cancers16112052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION The age of patients requiring surgery for spinal metastasis, primarily those over 65, has risen due to improved cancer treatments. Surgical intervention targets acute neurological deficits and instability. Anticoagulants are increasingly used, especially in the elderly, but pose challenges in managing bleeding complications. The study examines the correlation between preoperative anticoagulant/antiplatelet use and bleeding risks in spinal metastasis surgery, which is crucial for optimizing patient outcomes. MATERIAL AND METHODS In a retrospective study at our department from 2010 to 2023, spinal tumor surgery patients were analyzed. Data included demographics, neurological status, surgical procedure, preoperative anticoagulant/antiplatelet use, intra-/postoperative coagulation management, and the incidence of rebleeding. Coagulation management involved blood loss assessment, coagulation factor administration, and fluid balance monitoring post-surgery. Lab parameters were documented at admission, preop, postop, and discharge. RESULTS A cohort of 290 patients underwent surgical treatment for spinal metastases, predominantly males (63.8%, n = 185) with a median age of 65 years. Preoperatively, 24.1% (n = 70) were on oral anticoagulants or antiplatelet therapy. Within 30 days, a rebleeding rate of 4.5% (n = 9) occurred, unrelated to preoperative anticoagulation status (p > 0.05). A correlation was found between preoperative neurologic deficits (p = 0.004) and rebleeding risk and the number of levels treated surgically, with fewer levels associated with a higher incidence of postoperative bleeding (p < 0.01). CONCLUSIONS Surgical intervention for spinal metastatic cancer appears to be safe regardless of the patient's preoperative anticoagulation status. However, it remains imperative to customize preoperative planning and preparation for each patient, emphasizing meticulous risk-benefit analysis and optimizing perioperative care.
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Affiliation(s)
| | - Anto Abramovic
- Department of Neurosurgery, Medical University Innsbruck, 6020 Innsbruck, Austria; (C.O.); (C.T.)
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Faulkner H, Chakankar S, Mammi M, Lo JYT, Doucette J, Al-Otaibi N, Abboud J, Le A, Mekary RA, Bunevicius A. Safety and efficacy of prothrombin complex concentrate (PCC) for anticoagulation reversal in patients undergoing urgent neurosurgical procedures: a systematic review and metaanalysis. Neurosurg Rev 2020; 44:1921-1931. [PMID: 33009989 DOI: 10.1007/s10143-020-01406-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 09/28/2020] [Indexed: 12/31/2022]
Abstract
Anticoagulant therapy poses a significant risk for patients undergoing emergency neurosurgery procedures, necessitating reversal with prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). Data on PCC efficacy lack consistency in this setting. This systematic review and metaanalysis aimed to evaluate efficacy and safety of PCC for anticoagulation reversal in the context of urgent neurosurgery. Articles from PubMed, Embase, and Cochrane databases were screened according to the PRISMA checklist. Adult patients receiving anticoagulation reversal with PCC for emergency neurosurgical procedures were included. When available, patients who received FFP were included as a comparison group. Pooled estimates of observational studies were calculated for efficacy and safety outcomes via random-effects modeling. Initial search returned 4505 articles, of which 15 studies met the inclusion criteria. Anticoagulants used included warfarin (83%), rivaroxaban (6.8%), phenprocoumon (6.1%), apixaban (2.2%), and dabigatran (1.5%). The mean International Normalized Ratio (INR) prePCC administration ranged from 2.3 to 11.7, while postPCC administration from 1.1 to 1.4. All-cause mortality at 30 days was 27% (95%CI 21, 34%; I2 = 44.6%; p-heterogeneity = 0.03) and incidence of thromboembolic events was 6.00% among patients treated with PCC (95%CI 4.00, 10.0%; I2 = 0%; p-heterogeneity = 0.83). Results comparing PCC and FFP demonstrated no statistically significant differences in INR reversal, mortality, or incidence of thromboembolic events. This metaanalysis demonstrated adequate safety and efficacy for PCC in the reversal of anticoagulation for urgent neurosurgical procedures. There was no significant difference between PCC and FFP, though further trials would be useful in demonstrating the safety and efficacy of PCC in this setting.
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Affiliation(s)
| | | | - Marco Mammi
- Neurosurgery Unit, Department of Neurosciences, University of Turin, via Cherasco 15, 10126, Turin, Italy
| | - Jack Yu Tung Lo
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Department of Neurosurgery, National Neuroscience Institute, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore
| | - Joanne Doucette
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Nawaf Al-Otaibi
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Judi Abboud
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Andrew Le
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Rania A Mekary
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA. .,Neurosurgery Unit, Department of Neurosciences, University of Turin, via Cherasco 15, 10126, Turin, Italy.
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Agarwal P, Abdullah KG, Ramayya AG, Nayak NR, Lucas TH. A Retrospective Propensity Score-Matched Early Thromboembolic Event Analysis of Prothrombin Complex Concentrate vs Fresh Frozen Plasma for Warfarin Reversal Prior to Emergency Neurosurgical Procedures. Neurosurgery 2019; 82:877-886. [PMID: 29106685 DOI: 10.1093/neuros/nyx327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 05/16/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Reversal of therapeutic anticoagulation prior to emergency neurosurgical procedures is required in the setting of intracranial hemorrhage. Multifactor prothrombin complex concentrate (PCC) promises rapid efficacy but may increase the probability of thrombotic complications compared to fresh frozen plasma (FFP). OBJECTIVE To compare the rate of thrombotic complications in patients treated with PCC or FFP to reverse therapeutic anticoagulation prior to emergency neurosurgical procedures in the setting of intracranial hemorrhage at a level I trauma center. METHODS Sixty-three consecutive patients on warfarin therapy presenting with intracranial hemorrhage who received anticoagulation reversal prior to emergency neurosurgical procedures were retrospectively identified between 2007 and 2016. They were divided into 2 cohorts based on reversal agent, either PCC (n = 28) or FFP (n = 35). The thrombotic complications rates within 72 h of reversal were compared using the χ2 test. A multivariate propensity score matching analysis was used to limit the threat to interval validity from selection bias arising from differences in demographics, laboratory values, history, and clinical status. RESULTS Thrombotic complications were uncommon in this neurosurgical population, occurring in 1.59% (1/63) of treated patients. There was no significant difference in the thrombotic complication rate between groups, 3.57% (1/28; PCC group) vs 0% (0/35; FFP group). Propensity score matching analysis validated this finding after controlling for any selection bias. CONCLUSION In this limited sample, thrombotic complication rates were similar between use of PCC and FFP for anticoagulation reversal in the management of intracranial hemorrhage prior to emergency neurosurgical procedures.
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Affiliation(s)
- Prateek Agarwal
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kalil G Abdullah
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin G Ramayya
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil R Nayak
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy H Lucas
- Department of Neurosurgery, Center for Neuroengineering and Therapeutics, University of Pennsylvania, Philadelphia, Pennsylvania
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Prothrombin Complex Concentrates for Perioperative Vitamin K Antagonist and Non-vitamin K Anticoagulant Reversal. Anesthesiology 2019; 129:1171-1184. [PMID: 30157037 DOI: 10.1097/aln.0000000000002399] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Vitamin K antagonist therapy is associated with an increased bleeding risk, and clinicians often reverse anticoagulation in patients who require emergency surgical procedures. Current guidelines for rapid anticoagulation reversal for emergency surgery recommend four-factor prothrombin complex concentrate and vitamin K coadministration. The authors reviewed the current evidence on prothrombin complex concentrate treatment for vitamin K antagonist reversal in the perioperative setting, focusing on comparative studies and in the context of intracranial hemorrhage and cardiac surgery. The authors searched Cochrane Library and PubMed between January 2008 and December 2017 and retrieved 423 English-language papers, which they then screened for relevance to the perioperative setting; they identified 36 papers to include in this review. Prothrombin complex concentrate therapy was consistently shown to reduce international normalized ratio rapidly and control bleeding effectively. In comparative studies with plasma, prothrombin complex concentrate use was associated with a greater proportion of patients achieving target international normalized ratios rapidly, with improved hemostasis. No differences in thromboembolic event rates were seen between prothrombin complex concentrate and plasma, with prothrombin complex concentrate also demonstrating a lower risk of fluid overload events. Overall, the studies the authors reviewed support current recommendations favoring prothrombin complex concentrate therapy in patients requiring vitamin K antagonist reversal before emergency surgery.
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Beynon C, Olivares A, Gumbinger C, Younsi A, Zweckberger K, Unterberg AW. Management of Spinal Emergencies in Patients on Direct Oral Anticoagulants. World Neurosurg 2019; 131:e570-e578. [PMID: 31400524 DOI: 10.1016/j.wneu.2019.07.234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Spine surgeons increasingly encounter acute spinal pathologies in patients treated with direct oral anticoagulants (DOACs), but only limited data on the management of these patients are currently available. METHODS We retrospectively analyzed patients who presented to our department with acute spinal pathology during treatment with DOAC and who required urgent surgical therapy. Patient characteristics and treatment modalities were studied, with specific focus on the management of hemostasis and surgical therapy. Furthermore, we analyzed 19 cases of spinal emergencies during DOAC treatment reported in the literature. RESULTS A total of 12 patients were identified and included in the present analysis. Patients suffered from acute spinal cord compression caused by spinal tumor manifestation (n = 5), empyema (n = 4), degenerative spinal stenosis (n = 1), hematoma (n = 1), and vertebral body fracture/dislocation (n = 2). All patients underwent emergency surgical treatment. Prohemostatic substances were administered perioperatively in 10 patients (83%) and included administration of prothrombin complex concentrates (83%), tranexamic acid (17%), and transfusion of platelets (8%). A total of 9 patients (75%) showed postoperative improvement of neurologic symptoms, and the in-hospital mortality in this patient cohort was 17%. CONCLUSIONS Emergency spine surgery is feasible and should be considered in patients on treatment with DOAC. The (low) risk of intraoperative bleeding complications has to be weighed against the risk of permanent disability if surgical decompression is delayed. Administration of prothrombin complex concentrates and tranexamic acid may improve the coagulation before surgery, especially in cases of unavailable specific antidotes.
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Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Arturo Olivares
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Paulo D, Semonche A, Choudhry O, Al-Mufti F, Prestigiacomo CJ, Roychowdhury S, Nanda A, Gupta G. History of Hemostasis in Neurosurgery. World Neurosurg 2018; 124:S1878-8750(18)32837-7. [PMID: 30579020 DOI: 10.1016/j.wneu.2018.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/01/2018] [Accepted: 12/03/2018] [Indexed: 11/17/2022]
Abstract
Control of bleeding in the confined area of the skull is imperative for successful neurosurgery and the prevention of devastating complications such as postoperative hemorrhage. This paper reviews the historical evolution of methods to achieve successful hemostasis in neurosurgery from the early1800s to today. The major categories of hemostatic agents (mechanical, chemical and thermal) are delineated and discussed in chronological order. The significance of this article is in its detailed history of the kinds of hemostatic methods that have evolved with our accumulating medical and surgical knowledge, which may inform future innovations and improvements.
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Affiliation(s)
- Danika Paulo
- Rutgers Robert Wood Johnson Medical School, Department of Neurosurgery, Clinical Academic Building Suite 2100, 125 Paterson St, New Brunswick, NJ 08901, United States
| | - Alexa Semonche
- Rutgers Robert Wood Johnson Medical School, Department of Neurosurgery, Clinical Academic Building Suite 2100, 125 Paterson St, New Brunswick, NJ 08901, United States
| | - Osamah Choudhry
- New York University, Department of Neurological Surgery, 550 1st Avenue, Skirball, Suite 8R, New York, NY 10016, United States
| | - Fawaz Al-Mufti
- University Hospital, Department of Neurology, 90 Bergen Street, Suite 5200, Newark, NJ 07101, United States
| | - Charles J Prestigiacomo
- Rutgers New Jersey Medical School, Department of Neurosurgery, Doctor's Office Center 90 Bergen Street, Newark, NJ 07101, United States
| | - Sudipta Roychowdhury
- Robert Wood Johnson University Hospital, Department of Radiology, Medical Education Building Suite #04, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08901, United States
| | - Anil Nanda
- Robert Wood Johnson Medical School, Department of Neurosurgery, Clinical Academic Building Suite 2100, 125 Paterson St, New Brunswick, NJ 08901, United States
| | - Gaurav Gupta
- Robert Wood Johnson Medical School, Department of Neurosurgery, Clinical Academic Building Suite 2100, 125 Paterson St, New Brunswick, NJ 08901, United States.
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Abstract
Intraoperative bleeding can be minimized with optimal preoperative preparation but cannot be completely prevented. There are circumstances when patients need emergent operative intervention, and thorough hemostatic evaluation and preparation is not possible. In this review, the authors summarize the recommendations for rapid reversal of vitamin K antagonists and direct oral anticoagulants before procedures. The authors review the potential causes for intraoperative bleeding and the methods for rapid and accurate diagnosis. The authors summarize the current evidence for treatment options, including transfusion of platelets and coagulation factors and the use of topical agents, antidotes to direct-acting anticoagulants, antifibrinolytics, and desmopressin.
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Affiliation(s)
- Michal Bar-Natan
- Division of Hematology and Oncology, Department of Internal Medicine, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, 240 East 38th Street, 19th Floor, New York, NY 10016, USA
| | - Kenneth B Hymes
- Division of Hematology and Oncology, Department of Internal Medicine, Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, 240 East 38th Street, 19th Floor, New York, NY 10016, USA.
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Mačiukaitienė J, Bilskienė D, Tamašauskas A, Bunevičius A. Prothrombin Complex Concentrate for Warfarin-Associated Intracranial Bleeding in Neurosurgical Patients: A Single-Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2018; 54:E22. [PMID: 30344253 PMCID: PMC6037259 DOI: 10.3390/medicina54020022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/13/2018] [Accepted: 04/19/2018] [Indexed: 02/04/2023]
Abstract
Objective: The number of patients presenting with warfarin-associated intracranial bleeding and needing neurosurgical intervention is growing. Prothrombin complex concentrate (PCC) is commonly used for anti-coagulation reversal before emergent surgery. We present our experience with PCC use in patients presenting with coagulopathy and needing urgent craniotomy. Methods: We retrospectively identified all patients presenting with intracranial bleeding and coagulopathy due to warfarin use, requiring urgent neurosurgical procedures, from January, 2014 (implementation of 4-PCC therapy) until December, 2016. For coagulation reversal, all patients received 4-PCC (Octaplex) and vitamin K. Results: Thirty-five consecutive patients (17 men; median age 72 years) were administered 4-PCC before emergent neurosurgical procedures. The majority of patients presented with traumatic subdural hematoma (62%) and spontaneous intracerebral hemorrhage (32%). All patients were taking warfarin. Median international normalized ratio (INR) on admission was 2.94 (range: 1.20 to 8.60). Median 4-PCC dose was 2000 I.U. (range: 500 I.U. to 3000 I.U.). There was a statically significant decrease in INR (p < 0.01), PT (p < 0.01), and PTT (p = 0.02) after 4-PCC administration. Postoperative INR values were ≤3.00 in all patients, and seven (20%) patients had normal INR values. There were no 4-PCC related complications. Four (11%) patients developed subdural/epidural hematoma and 20 (57%) patients died. Mortality was associated with lower Glasgow coma scale (GCS) score. Conclusions: The 4-PCC facilitates INR reversal and surgery in patients presenting with warfarin-associated coagulopathy and intracranial bleeding requiring urgent neurosurgical intervention.
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Affiliation(s)
- Jomantė Mačiukaitienė
- Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, LT-50009 Kaunas, Lithuania.
| | - Diana Bilskienė
- Department of Anesthesiology, Medical Academy, Lithuanian University of Health Sciences, LT-50009 Kaunas, Lithuania.
| | - Arimantas Tamašauskas
- Neuroscience Institute, Medical Academy, Lithuanian University of Health Sciences, LT-50009 Kaunas, Lithuania.
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, LT-50009 Kaunas, Lithuania.
| | - Adomas Bunevičius
- Neuroscience Institute, Medical Academy, Lithuanian University of Health Sciences, LT-50009 Kaunas, Lithuania.
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, LT-50009 Kaunas, Lithuania.
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Sin JH, Berger K, Lesch CA. Four-factor prothrombin complex concentrate for life-threatening bleeds or emergent surgery: A retrospective evaluation. J Crit Care 2016; 36:166-172. [PMID: 27546767 DOI: 10.1016/j.jcrc.2016.06.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 06/01/2016] [Accepted: 06/28/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Previous trials investigating usage of four-factor prothrombin complex concentrate (4F-PCC) excluded patients with various thrombotic risk factors. The objective of this study was to evaluate the safety and effectiveness of 4F-PCC in a real-world setting based on an institutional protocol that does not have strict exclusion criteria. METHODS This was a retrospective study of adult patients who received 4F-PCC. The primary outcome was a confirmed thromboembolism within 14 days after 4F-PCC administration. Secondary outcomes included international normalized ratio (INR) correction to <1.5 at first draw and incidence of INR rebound for patients undergoing reversal of warfarin and hemostatic effectiveness for patients experiencing a bleed. RESULTS Ninety-three patients received 4F-PCC. Sixty-three (67.7%) were reversed for bleeding and 30 (32.3%) for surgery. Eleven patients (11.8%) developed a thromboembolism within 14 days. The median (interquartile range) time to event was 5 (2-7) days. Significant risk factors were heparin-induced thrombocytopenia (P= .01) and major surgery within 14 days (P= .02), as well as the presence of >6 thrombotic risk factors (P= .01). For patients post-warfarin reversal, 45/63 (71.4%) achieved INR correction at first draw, 55/63 (87.3%) achieved INR correction within 24 hours, and 14/55 (25.5%) experienced INR rebound. Of these 14 patients, 8 (57.1%) did not receive concomitant vitamin K. CONCLUSIONS 4F-PCC was associated with a notable thromboembolic risk. All patient-specific risk factors should be considered prior to administration. 4F-PCC remains a useful agent for warfarin reversal. Lack of concomitant vitamin K may contribute to INR rebound.
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Affiliation(s)
- Jonathan H Sin
- NewYork-Presbyterian Hospital, Weill Cornell Medical Center, Department of Pharmacy, 525 East 68th Street, New York, NY 10065.
| | - Karen Berger
- NewYork-Presbyterian Hospital, Weill Cornell Medical Center, Department of Pharmacy, 525 East 68th Street, New York, NY 10065
| | - Christine A Lesch
- NewYork-Presbyterian Hospital, Columbia University Medical Center, Department of Pharmacy, 630 West 168th Street, New York, NY 10032.
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