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Wilhelmy F, Gaier M, Planitzer U, Kasper J, Prasse G, Frydrychowicz C, Oesemann R, Meixensberger J, Lindner D. Venous thromboembolism and intracranial hemorrhage in patients undergoing glioblastoma surgery. Sci Rep 2023; 13:21679. [PMID: 38066037 PMCID: PMC10709630 DOI: 10.1038/s41598-023-48542-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
In the perioperative management of patients with glioblastoma (GBM), physicians face the question of whether and when to administer prophylactic or therapeutic anticoagulation (AC). In this study, we investigate the effects of the timing of postoperative heparinization on thromboembolic events (TE) and postoperative hemorrhage (bleeding, PH) as well as the interactions between the two in the context of an underlying intracerebral malignancy. For this retrospective data analysis, 222 patients who underwent surgery for grade IV glioblastoma, IDH-wildtype (2016 CNS WHO) between 01/01/2014 and 31/12/2019 were included. We followed up for 12 months. We assessed various biographical and clinical data for risk factors and focused on the connection between timepoint of AC and adverse events. Subgroup analyses were performed for pulmonary artery embolism (PE), deep vein thrombosis, and postoperative intracranial hemorrhage (PH) that either required surgical intervention or was controlled radiologically only. Statistical analysis was performed using Mann-Whitney U-Test, Chi-square test, Fisher's exact test and univariate binomial logistic regression. p values below 0.05 were considered statistically significant. There was no significant association between prophylactic AC within 24 h and more frequent major bleeding (p = 0.350). AC in patients who developed major bleeding was regularly postponed by the physician/surgeon upon detection of the re-bleeding; therefore, patients with PH were anticoagulated significantly later (p = 0.034). The timing of anticoagulant administration did not differ significantly between patients who experienced a thromboembolic event and those who did not (p = 0.634). There was considerable overlap between the groups. Three of the six patients (50%) with PE had to be lysed or therapeutically anticoagulated and thereafter developed major bleeding (p < 0.001). Patients who experienced TE were more likely to die during hospitalization than those with major bleeding (p = 0.022 vs. p = 1.00). Prophylactic AC within 24 h after surgery does not result in more frequent bleeding. Our data suggests that postoperative intracranial hemorrhage is not caused by prophylactic AC but rather is a surgical complication or the result of antithrombotic therapy. However, thromboembolic events worsen patient outcomes far more than postoperative bleeding. The fact that bleeding may occur as a complication of life-saving lysis therapy in the setting of a thromboembolic event should be included in this cost-benefit consideration.
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Affiliation(s)
- Florian Wilhelmy
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Michael Gaier
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Uwe Planitzer
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Johannes Kasper
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Gordian Prasse
- Division of Neuroradiology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Clara Frydrychowicz
- Division of Neuropathology, University Hospital Leipzig, Liebigstrasse 26, 04103, Leipzig, Germany
| | - René Oesemann
- Department of Anesthesiology and Intensive Care, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Jürgen Meixensberger
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Su ZJ, Wang HR, Liu LQ, Li N, Hong XY. Analysis of risk factors for postoperative deep vein thrombosis after craniotomy and nomogram model construction. World J Clin Cases 2023; 11:7543-7552. [DOI: 10.12998/wjcc.v11.i31.7543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/05/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Deep vein thrombosis (DVT) of the lower extremity is one of the most common postoperative complications, especially after craniocerebral surgery. DVT may lead to pulmonary embolism, which has a devastating impact on patient prognosis. This study aimed to investigate the incidence and risk factors of DVT in the lower limbs following craniocerebral surgery.
AIM To identify independent risk factors for the development of postoperative DVT and to develop an effective risk prediction model.
METHODS The demographic and clinical data of 283 patients who underwent craniocerebral surgery between December 2021 and December 2022 were retrospectively analyzed. The independent risk factors for lower extremity DVT were identified by univariate and multivariate analyses. A nomogram was created to predict the likelihood of lower extremity DVT in patients who had undergone craniocerebral surgery. The efficacy of the prediction model was determined by receiver operating characteristic curve using the probability of lower extremity DVT for each sample.
RESULTS Among all patients included in the analysis, 47.7% developed lower extremity DVT following craniocerebral surgery. The risk of postoperative DVT was higher in those with a longer operative time, and patients with intraoperative intermittent pneumatic compression were less likely to develop postoperative DVT.
CONCLUSION The incidence of lower extremity DVT following craniocerebral surgery is significant, highlighting the importance of identifying independent risk factors. Interventions such as the use of intermittent pneumatic compression during surgery may prevent the formation of postoperative DVT.
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Affiliation(s)
- Zhen-Jin Su
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Hong-Rui Wang
- Department of Operating Theater, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Li-Qin Liu
- Department of Operating Theater, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Nan Li
- Department of Operating Theater, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Xin-Yu Hong
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun 130000, Jilin Province, China
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Kilgore CB, Nair SK, Ran KR, Caplan JM, Jackson CM, Gonzalez LF, Huang J, Tamargo RJ, Xu R. Venous thromboembolism in aneurysmal subarachnoid hemorrhage: Risk factors and timing of chemoprophylaxis. Clin Neurol Neurosurg 2023; 231:107822. [PMID: 37295198 PMCID: PMC11097649 DOI: 10.1016/j.clineuro.2023.107822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/27/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a significant contributor to morbidity and mortality among patients recovering from aneurysmal subarachnoid hemorrhage (aSAH). Prophylactic heparin reduces the risk of VTE, but the optimal timing for its initiation among aSAH patients remains unclear. OBJECTIVE To conduct a retrospective study assessing risk factors for VTE and optimal timing of chemoprophylaxis in patients treated for aSAH. METHODS From 2016-2020, 194 adult patients were treated for aSAH at our institution. Patient demographics, clinical diagnoses, complications, pharmacologic interventions, and outcomes were recorded. Risk factors for symptomatic VTE (sVTE) were analyzed via Chi-squared, univariate, and multivariate regression. RESULTS In total 33 patients presented with sVTE (25 DVT, 14 PE). Patients with sVTE had longer hospital stays (p < 0.01) and worse outcomes at one-month (p < 0.01) and three-month follow-up (p = 0.02). Univariate predictors of sVTE included male sex (p = 0.03), Hunt Hess score (p = 0.01), Glasgow Coma scale (p = 0.02), intracranial hemorrhage (p = 0.03), hydrocephalus requiring external ventricular drain (EVD) placement (p < 0.01), and mechanical ventilation (p < 0.01). Only hydrocephalus requiring EVD (p = 0.01) and ventilator use (p = 0.02) remained significant upon multivariate analysis. Patients with delayed heparin introduction were significantly more likely to sustain sVTE on univariate analysis (p = 0.02) with a trend-level significance on multivariate analysis (p = 0.07). CONCLUSIONS Patients with aSAH are more likely to develop sVTE following use of perioperative EVD or mechanical ventilation. sVTE leads to longer hospital stays and worse outcomes among patients treated for aSAH. Delayed heparin initiation increases the risk of sVTE. Our results may help guide surgical decision-making during recovery from aSAH and improve VTE-related postoperative outcomes.
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Affiliation(s)
- Collin B Kilgore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen R Ran
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Foglar M, Aumiller M, Bochmann K, Buchner A, El Fahim M, Quach S, Sroka R, Stepp H, Thon N, Forbrig R, Rühm A. Interstitial Photodynamic Therapy of Glioblastomas: A Long-Term Follow-up Analysis of Survival and Volumetric MRI Data. Cancers (Basel) 2023; 15:cancers15092603. [PMID: 37174068 PMCID: PMC10177153 DOI: 10.3390/cancers15092603] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The treatment of glioblastomas, the most common primary malignant brain tumors, with a devastating survival perspective, remains a major challenge in medicine. Among the recently explored therapeutic approaches, 5-aminolevulinic acid (5-ALA)-mediated interstitial photodynamic therapy (iPDT) has shown promising results. METHODS A total of 16 patients suffering from de novo glioblastomas and undergoing iPDT as their primary treatment were retrospectively analyzed regarding survival and the characteristic tissue regions discernible in the MRI data before treatment and during follow-up. These regions were segmented at different stages and were analyzed, especially regarding their relation to survival. RESULTS In comparison to the reference cohorts treated with other therapies, the iPDT cohort showed a significantly prolonged progression-free survival (PFS) and overall survival (OS). A total of 10 of 16 patients experienced prolonged OS (≥ 24 months). The dominant prognosis-affecting factor was the MGMT promoter methylation status (methylated: median PFS of 35.7 months and median OS of 43.9 months) (unmethylated: median PFS of 8.3 months and median OS of 15.0 months) (combined: median PFS of 16.4 months and median OS of 28.0 months). Several parameters with a known prognostic relevance to survival after standard treatment were not found to be relevant to this iPDT cohort, such as the necrosis-tumor ratio, tumor volume, and posttreatment contrast enhancement. After iPDT, a characteristic structure (iPDT remnant) appeared in the MRI data in the former tumor area. CONCLUSIONS In this study, iPDT showed its potential as a treatment option for glioblastomas, with a large fraction of patients having prolonged OS. Parameters of prognostic relevance could be derived from the patient characteristics and MRI data, but they may partially need to be interpreted differently compared to the standard of care.
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Affiliation(s)
- Marco Foglar
- Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Maximilian Aumiller
- Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, 81377 Munich, Germany
- Department of Urology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Katja Bochmann
- Max Planck Institute for Psychiatry, Max Planck Society, 80804 Munich, Germany
- Institute of Neuroradiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Alexander Buchner
- Department of Urology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Mohamed El Fahim
- Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Stefanie Quach
- Department of Neurosurgery, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Ronald Sroka
- Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, 81377 Munich, Germany
- Department of Urology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Herbert Stepp
- Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, 81377 Munich, Germany
- Department of Urology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Niklas Thon
- Department of Neurosurgery, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Robert Forbrig
- Institute of Neuroradiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Adrian Rühm
- Laser-Forschungslabor, LIFE Center, University Hospital, LMU Munich, 81377 Munich, Germany
- Department of Urology, University Hospital, LMU Munich, 81377 Munich, Germany
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Abunimer AM, Lak AM, Calvachi P, Smith TR, Aglio LS, Almefty KK, Dunn IF, Bi WL, Goldhaber SZ, Al-Mefty O. Early Detection and Management of Venous Thrombosis in Skull Base Surgery: Role of Routine Doppler Ultrasound Monitoring. Neurosurgery 2022; 91:115-122. [PMID: 35383697 DOI: 10.1227/neu.0000000000001936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), encompassing deep venous thrombosis (DVT) and pulmonary embolism (PE), causes postoperative morbidity and mortality in neurosurgical patients. The use of pharmacological prophylaxis for DVT prevention in the immediate postoperative period carries increased risk of intracranial hemorrhage, especially after skull base surgeries. OBJECTIVE To investigate the impact of routine Doppler ultrasound monitoring in prevention and tiered management of VTE after skull base surgery. METHODS We retrospectively analyzed a large cohort of consecutive adult patients who were prospectively and uniformly managed with routine monitoring by Doppler ultrasound for DVT after resection of a skull base tumor. RESULTS A total of 389 patients who underwent 459 surgeries for intracranial tumor resection were analyzed. Skull base meningioma was the most common pathology. Forty-four (9.59%) postoperative VTEs were detected: 9 (1.96%) with PE with or without DVT and 35 (7.63%) with DVT alone. Four cases of subsegmental PE were diagnosed without evidence of lower extremity DVT, possibly in the setting of peripherally inserted central catheters maintenance. One patient had a preoperative proximal DVT and underwent a prophylactic inferior vena cava filter but expired from PE after discharge. Prior history of VTE (risk ratio [RR] 5.13; 95% CI 2.76-7.18; P < .01), anesthesia duration (RR 1.14; 95% CI 1.03-1.27; P = .02), and blood transfusion (RR 1.95; 95% CI 1.01-3.37; P = .04) were associated with VTE development on multivariate analysis. CONCLUSION Routine postoperative venous ultrasound monitoring detects asymptomatic DVT guiding management. This is an alternative strategy to prescribing pharmacological VTE prophylaxis immediately after lengthy surgeries for intracranial tumors. Peripherally inserted central catheters were associated with subsegmental PE.
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Affiliation(s)
- Abdullah M Abunimer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Asad M Lak
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paola Calvachi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Linda S Aglio
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kaith K Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Feler J, Sun F, Bajaj A, Hagan M, Kanekar S, Sullivan PLZ, Fridley JS, Gokaslan ZL. Complication Avoidance in Surgical Management of Vertebral Column Tumors. Curr Oncol 2022; 29:1442-1454. [PMID: 35323321 PMCID: PMC8947448 DOI: 10.3390/curroncol29030121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/23/2022] Open
Abstract
The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.
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Affiliation(s)
- Joshua Feler
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Felicia Sun
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Ankush Bajaj
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Matthew Hagan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Samika Kanekar
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
| | - Patricia Leigh Zadnik Sullivan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Jared S. Fridley
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
| | - Ziya L. Gokaslan
- The Warren Alpert Medical School of Brown University, Providence, RI 02912, USA; (J.F.); (F.S.); (A.B.); (M.H.); (S.K.); (P.L.Z.S.); (J.S.F.)
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI 02903, USA
- Correspondence:
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Neurosurgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Hantsche A, Wilhelmy F, Kasper J, Wende T, Hamerla G, Rasche S, Meixensberger J, Lindner D. Early prophylactic anticoagulation after subarachnoid hemorrhage decreases systemic ischemia and improves outcome. Clin Neurol Neurosurg 2021; 207:106809. [PMID: 34274657 DOI: 10.1016/j.clineuro.2021.106809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 06/23/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND In neurosurgical perioperative treatment, especially in connection with subarachnoid hemorrhage (SAH), the prophylactic anticoagulation (AC) regimen is still considered controversial. The goal of this retrospective study was to assess how the time point of low-molecular-weight heparin (LMWH) initiation (ToH) affects ischemic and hemorrhagic events after SAH. METHODS 370 patients who received acute treatment for non-traumatic SAH between 2011 and 2018 were included, and 208 patients were followed up after 12 months. We assessed how the ToH affects ischemic and hemorrhagic events as well as outcome scores. Statistical analysis was performed using the Mann-Whitney U-Test, the chi-squared test, Fisher's exact test, and univariate binomial logistic regression. P-values below 0.05 were considered statistically significant. RESULTS The incidence of systemic ischemia was 4.6%, cerebral ischemia 33.5%, and intracranial rebleeding 14.6%. Delaying ToH (measured in hours) increases systemic ischemia (p = 0.009). The odds ratio for the impact of delayed anticoagulation on systemic ischemia is 1.013 per hour (95%CI of OR 1.001-1.024). ToH has no influence on cerebral ischemia or intracranial rebleeding. Early anticoagulation was associated with a more favorable Glasgow Outcome Score 12 months after discharge (ToH within 48 h: p = 0.006). ToH did not affect mortality or readmission rates. CONCLUSIONS Initiating prophylactic AC with LMWH later than 48 h after aneurysm repair or admission impairs outcomes 12 months after discharge. It might be safe for patients with non-traumatic SAH to be anticoagulated with prophylactic doses of heparin within 24 h after admission or the treatment of source of bleeding (SoB). Early AC with prophylactic LMWH does not promote rebleeding.
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Affiliation(s)
- Annika Hantsche
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Florian Wilhelmy
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany.
| | - Johannes Kasper
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Tim Wende
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Gordian Hamerla
- University Hospital Leipzig, Division of Neuroradiology, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Stefan Rasche
- University Hospital Leipzig, Department of Anesthesiology and Intensive Care, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Jürgen Meixensberger
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Dirk Lindner
- University Hospital Leipzig, Department of Neurosurgery, Liebigstrasse 20, 04103 Leipzig, Germany
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9
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Naeem K, Bhargava M, Bohl M, Porter RW. Posterior Fossa Hemorrhage Following the Use of Low-Molecular-Weight Heparin: Lessons Learned and Recommendations for the Treatment and Prophylaxis of Postoperative Venous Thromboembolism. Cureus 2021; 13:e15404. [PMID: 34249552 PMCID: PMC8253580 DOI: 10.7759/cureus.15404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 04/30/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Venous thromboembolism (VTE) is the most common preventable cause of morbidity and mortality among neurosurgery patients. Several studies have concluded that the use of chemical prophylaxis among patients undergoing a craniotomy reduces the incidence of VTE, and it is presumed to be safe. However, these studies do not differentiate between a supratentorial and posterior fossa craniotomy. Furthermore, the prophylactic or therapeutic use of low-molecular-weight heparin (LMWH) has been reported to increase the risk of intracranial hemorrhage. In this study, we describe the clinical details and outcomes for all patients who underwent posterior fossa craniotomy and developed posterior fossa hemorrhage secondary to postoperative use of LMWH during the study period. We also propose recommendations pertaining to postoperative heparin use after posterior fossa surgeries. Methods Data were retrospectively collected for patients presenting with posterior fossa hemorrhage following anticoagulant use among those who previously underwent posterior fossa craniotomy by the senior author (R.W.P.) from January 1, 2011, through December 31, 2018. Results We identified five patients who experienced postoperative hemorrhage while receiving LMWH in the initial setting of posterior fossa craniotomy. After hemorrhaging, four patients had low Glasgow Outcome Scale (GOS) scores (≤3) and failed to return to their baseline neurological status. These four patients had a Glasgow Coma Scale (GCS) score of 15/15 in the immediate postoperative period and received heparin within 72 hours of surgery. Conclusions Based on our findings, there is a possible association between the increased risk of hemorrhage and the early postoperative use of LMWH. The debilitating outcomes among the majority of these patients warrant the cautious use and further investigation of postoperative LMWH to appropriately quantify the risk. Further comparative studies with a larger sample size are required to provide insight into the pathophysiology of our findings.
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Affiliation(s)
- Komal Naeem
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA
| | - Malika Bhargava
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA
| | - Michael Bohl
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA
| | - Randall W Porter
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, USA
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Schneck MJ. Neurologic complications of venous thromboembolism. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:261-267. [PMID: 33632445 DOI: 10.1016/b978-0-12-819814-8.00017-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Patients with neurologic disease are at high risk of venous thromboembolism (VTE). The converse risk of neurological complications in concert or following peripheral VTE is rarely considered. The major neurologic complication following pulmonary embolism or peripheral VTE is intracranial hemorrhage that occurs following anticoagulation therapy for VTE. Ischemic stroke may occur concomitantly with VTE. VT occurrence may also be a marker for a future increased risk of stroke. Peripheral neuropathy may occur or neuropathic pain may occur as a result of thrombophlebitis following deep venous thrombosis. Other sequelae of VTE are somewhat theoretical including the discovery of central nervous system malignancies after incident VTE.
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Affiliation(s)
- Michael J Schneck
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, United States.
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11
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Fluss R, Kobets AJ, Inocencio JF, Hamad M, Feigen C, Altschul DJ, Lasala P. The incidence of venous thromboembolism following surgical resection of intracranial and intraspinal meningioma. A systematic review and retrospective study. Clin Neurol Neurosurg 2021; 201:106460. [PMID: 33444944 DOI: 10.1016/j.clineuro.2020.106460] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Historically, the development of venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary thromboembolism (PE) was cited as a higher post-operative risk for patients harboring meningiomas. However, recent literature has suggested that there may be no elevated risk for VTE among these patients. The authors perform both a retrospective review of their own cases as well as a systematic review of the literature in order to determine the frequency of the VTE and rate of post-operative hemorrhage in this patient population. METHODOLOGY Patients undergoing surgery for intracranial and spinal meningioma from 2012 to 2019 were retrospectively reviewed for patient demographics, clinical characteristics, and post-operative complications. Logistic regression was used to determine risk factors for the development of VTE. Additionally, a PubMed search was performed to identify patients addressing this topic. RESULTS Our retrospective review included 189 patients who underwent 197 operations. The rate of VTE for patients receiving LMWH was 3.55 % vs. 4.06 % for those not receiving LMWH. There were no observed hemorrhages after initiation of LMWH. Multivariate analysis found tumor volume, history of DVT, and length of hospital stay as independent risk factors for VTE. In the systematic review, 11 papers describing 28,954 patients were included. The risk of developing a VTE with or without LMWH was 2.71 % versus 4.07 %, respectively. The hemorrhage risk was 2.23 % on LMWH versus 4.20 % not on LMWH. DISCUSSION In several heterogeneous series of all types of neurosurgical procedures, the reported rate of VTE was 11.1 %. In our review of the literature, the VTE rate of 2.71 % was similar to our cohort's rate of 3.55 %, for patients administered LMWH postoperatively. Higher rates of VTE with meningiomas may not be the case as once thought. Regular use of LMWH appears to be a safe, but it also did not necessarily lower the rates of VTE in our cohort. The use of routine lower-extremity duplex ultrasound, mechanical prophylaxis, and early mobilization, may have contributed to these lower rates of VTEs in patients with meningiomas.
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Affiliation(s)
- Rose Fluss
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Einstein College of Medicine, Bronx, NY, United States
| | - Andrew J Kobets
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Einstein College of Medicine, Bronx, NY, United States.
| | - Julio F Inocencio
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Einstein College of Medicine, Bronx, NY, United States
| | - Mousa Hamad
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Einstein College of Medicine, Bronx, NY, United States
| | - Chaim Feigen
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Einstein College of Medicine, Bronx, NY, United States
| | - David J Altschul
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Einstein College of Medicine, Bronx, NY, United States
| | - Patrick Lasala
- Leo M. Davidoff Department of Neurological Surgery, Montefiore Medical Center, Einstein College of Medicine, Bronx, NY, United States
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12
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Moorthy V, Wang JX, Tang JH, Oh JYL. Postoperative spinal epidural hematoma following therapeutic anticoagulation: case report and review of literature. JOURNAL OF SPINE SURGERY 2020; 6:743-749. [PMID: 33447677 DOI: 10.21037/jss-20-636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
While the incidence and risk factors of pulmonary embolism (PE) and deep vein thrombosis (DVT) following spinal surgery have been well studied, the treatment of such thromboembolic disease in patients after spine surgery remains controversial. When initiating therapeutic anticoagulation after spine surgery, clinicians must weigh the catastrophic risk of a PE against the risk of bleeding complications associated with anticoagulation therapy. Here we report the case of a 56-year-old male who presented with symptoms of spinal cord compression secondary to metastatic renal cell carcinoma (RCC). An inferior vena cava (IVC) filter was inserted preoperatively and urgent decompression at the thoraco-lumbar region was performed. Therapeutic clexane was started on postoperative day (POD) 7 and he was discharged. On POD 8, he was readmitted following acute bilateral lower limb paralysis. Magnetic resonance imaging (MRI) revealed a large posterior spinal epidural hematoma with severe compression of the conus at L1 level. Urgent posterior decompression was performed but subsequent recovery was slow and incomplete. His power improved gradually over the right lower limb with attainment of grade 4/5 motor power but still had hemiparesis on his left lower limb upon discharge out of hospital. This case highlights the risk of starting therapeutic anticoagulation following spinal surgery. Prior to starting treatment, the clinician must consider the appropriate dose, timing and alternatives available to avoid unnecessary complications.
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Affiliation(s)
- Vikaesh Moorthy
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
| | | | - Jun Han Tang
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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13
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Wilhelmy F, Hantsche A, Wende T, Kasper J, Reuschel V, Frydrychowicz C, Rasche S, Lindner D, Meixensberger J. Perioperative anticoagulation in patients with intracranial meningioma: No increased risk of intracranial hemorrhage? PLoS One 2020; 15:e0238387. [PMID: 32870937 PMCID: PMC7462284 DOI: 10.1371/journal.pone.0238387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Anticoagulation (AC) is a critical topic in perioperative and post-bleeding management. Nevertheless, there is a lack of data about the safe, judicious use of prophylactic and therapeutic anticoagulation with regard to risk factors and the cause and modality of brain tissue damage as well as unfavorable outcomes such as postoperative hemorrhage (PH) and thromboembolic events (TE) in neurosurgical patients. We therefore present retrospective data on perioperative anticoagulation in meningioma surgery. METHODS Data of 286 patients undergoing meningioma surgery between 2006 and 2018 were analyzed. We followed up on anticoagulation management, doses and time points of first application, laboratory values, and adverse events such as PH and TE. Pre-existing medication and hemostatic conditions were evaluated. The time course of patients was measured as overall survival, readmission within 30 days after surgery, as well as Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS). Statistical analysis was performed using multivariate regression. RESULTS We carried out AC with Fraxiparin and, starting in 2015, Tinzaparin in weight-adapted recommended prophylactic doses. Delayed (216 ± 228h) AC was associated with a significantly increased rate of TE (p = 0.026). Early (29 ± 21.9h) prophylactic AC, on the other hand, did not increase the risk of PH. We identified additional risk factors for PH, such as blood pressure maxima, steroid treatment, and increased white blood cell count. Patients' outcome was affected more adversely by TE than PH (+3 points in modified Rankin Scale in TE vs. +1 point in PH, p = 0.001). CONCLUSION Early prophylactic AC is not associated with an increased rate of PH. The risks of TE seem to outweigh those of PH. Early postoperative prophylactic AC in patients undergoing intracranial meningioma resection should be considered.
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Affiliation(s)
- Florian Wilhelmy
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Annika Hantsche
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Tim Wende
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Johannes Kasper
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Vera Reuschel
- Division of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Stefan Rasche
- Department of Anesthesiology and Intensive Care, University Hospital Leipzig, Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
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McConachie SM, Morin A, Mouabbi K, Soubani AO, Wahby K. Prophylactic unfractionated heparin and hemorrhage in neurocritically ill underweight patients: A case series and review of the literature. Am J Health Syst Pharm 2020; 77:1571-1577. [PMID: 32815544 DOI: 10.1093/ajhp/zxaa225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Three cases of major bleeding associated with thromboprophylactic unfractionated heparin (UFH) therapy in underweight neurocritically ill patients are reported. SUMMARY Three underweight patients (body mass index of <18.5 kg/m2) were treated in the intensive care unit with major bleeds associated with UFH thromboprophylaxis. Two of the patients, a 76-year-old female and a 56-year-old female, had hemorrhages on presentation; the third patient, a 29-year-old male, developed bleeding during his admission. All 3 patients had past medical histories consisting of acute neurologic conditions within 6 weeks of presentation, including subdural hematoma, subarachnoid hemorrhage, and obstructive hydrocephalus secondary to a brain mass. All hemorrhages developed following the receipt of prophylactic UFH at doses of 5,000 units every 8 to 12 hours, which translated to high weight-based dosages (>300 units/kg/d). Additionally, hemorrhages were associated with prolonged activated partial thromboplastin time, which declined following heparin discontinuation. The major bleeds following UFH administration included an acute on chronic subdural hematoma, acute rectus sheath hematoma, and cerebellar hematoma. Stabilization of the subdural hematoma was achieved without the use of protamine and the patient was discharged in stable condition. The other 2 patients expired secondary to their hemorrhagic events. Naranjo nomogram scores for the patients indicated that heparin was the probable cause of bleed in 2 cases and a possible cause in 1 case. CONCLUSION Three major hemorrhages developed following the administration of UFH. Underweight patients with neurologic injury may require increased clinical vigilance, reduced doses, and pharmacodynamic monitoring to improve safety outcomes associated with thromboprophylaxis.
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Affiliation(s)
- Sean M McConachie
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI.,Beaumont Hospital, Dearborn, Dearborn, MI
| | - Amy Morin
- Blue Cross Blue Shield of Michigan, Detroit, MI
| | - Karim Mouabbi
- Department of Pharmacy Services, Harper University Hospital, Detroit, MI
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Detroit Medical Center and School of Medicine, Wayne State University, Detroit, MI
| | - Krista Wahby
- Department of Pharmacy Services, Harper University Hospital, Detroit, MI
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15
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Colomina MJ, Bagó J, Pérez-Bracchiglione J, Nishishinya Aquino MB, Salas KR, Requeijo C, Urrútia G. Thromboprophylaxis in elective spinal surgery: A protocol for systematic review. Medicine (Baltimore) 2020; 99:e20127. [PMID: 32481281 PMCID: PMC7249943 DOI: 10.1097/md.0000000000020127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious, sometimes life-threatening complication that can occur following spine surgery. The incidence of VTE, and the optimal type and timing of thromboprophylaxis for this complication in elective spine surgery is a matter of debate. OBJECTIVE To perform a systematic review with the aim of clarifying the efficacy and adverse effects of mechanical and chemical prophylaxis for preventing thromboembolic complications in elective spine surgery for conditions other than trauma and malignant disease. METHODS/DESIGN A search strategy of related articles up to March 2018 was designed and executed in Medline and Embase. PATIENTS adolescents (>10 years) and adults undergoing elective surgery for spinal deformity or degenerative disease (from C1 to S1). INTERVENTION Perioperative mechanical and chemical thromboprophylaxis. Studies could be randomized controlled trials or observational studies that reported data on any relevant clinical outcomes. RESULTS In total, 2451 uniquecitations were identified and 35 studies were ultimately included in the systematic review. The overall mean incidence of complications was 3.7% for deep venous thrombosis, 0.0% for pulmonary embolism, and 3.7% for bleeding in chemoprophylaxis group; 2.9% for deep venous thrombosis, 0.4% for pulmonary embolism and 0.0% for bleeding in mechanoprophylaxis; and 0.7% for deep venous thrombosis, 0.1% for pulmonary embolism and 0.2% for bleeding in mixed prophylaxis group with no specific data on these rates for the type of patient and type and location of surgery. None of the articles retrieved provided information on the adolescent population. DISCUSSION AND CONCLUSIONS The poor design and high variability among the studies regarding characteristics of study population, details of interventions, and definitions of outcomes, determines a low quality of the available evidence and limits the interpretation of the results. We were unable to identify a clear advantage of one type of thromboprophylaxis over the other, although there was an increased risk of bleeding with chemoprophylaxis, which could favor the use of mechanoprophylaxis in this scenario.
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Affiliation(s)
- María J. Colomina
- Department of Anaesthesiology and Intensive Care, Hospital Universitari Bellvitge, L’Hospitalet de LLobregat, Barcelona, Universitat de Barcelona
| | - Joan Bagó
- Spine Surgery Unit, Department of Orthopedic and Trauma Surgery, Hospital Universitari Vall d’Hebron, Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Karla R. Salas
- Iberoamerican Cochrane Centre, Sant Pau Biomedical Research Institute (IIB Sant Pau)
| | - Carolina Requeijo
- Iberoamerican Cochrane Centre, Sant Pau Biomedical Research Institute (IIB Sant Pau)
| | - Gerard Urrútia
- Iberoamerican Cochrane Centre, Sant Pau Biomedical Research Institute (IIB Sant Pau), CIBERESP, Barcelona, Spain
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What Is the Safety and Efficacy of Chemical Venous Thromboembolism Prophylaxis Following Vestibular Schwannoma Surgery? Otol Neurotol 2019; 39:e131-e136. [PMID: 29227440 DOI: 10.1097/mao.0000000000001633] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The benefit of routine chemical prophylaxis use for venous thromboembolism (VTE) prevention in skull base surgery is controversial. Chemical prophylaxis can prevent undue morbidity and mortality, however there are risks for hemorrhagic complications. STUDY DESIGN Retrospective case-control. METHODS A retrospective chart review of patients who underwent surgery for vestibular schwannoma from 2011 to 2016 was performed. Patients were divided by receipt of chemical VTE prophylaxis. Number of VTEs and hemorrhagic complications (intracranial hemorrhage, abdominal hematoma, and postauricular hematoma) were recorded. RESULTS One hundred twenty-six patients were identified, 55 received chemical prophylaxis, and 71 did not. All the patients received mechanical prophylaxis. Two patients developed a deep vein thrombosis (DVT) and one patient developed a pulmonary embolism (PE). All patients who developed a DVT or PE received chemical prophylaxis. There was no difference in DVT (p = 0.1886) or PE (p = 0.4365) between those who received chemical prophylaxis and those who did not. Five patients developed a hemorrhagic complication, two intracranial hemorrhage, three abdominal hematoma, and zero postauricular hematoma. All five patients with a complication received chemical prophylaxis (p = 0.00142). The relative risk of a hemorrhagic complication was 14.14 (95% CI = 0.7987-250.4307; p = 0.0778). CONCLUSION There was a significant difference between the number of hemorrhagic complications but not between numbers of DVT or PE. Mechanical and chemical prophylaxis may lower the risk of VTE but in our series, hemorrhagic complications were observed. These measures should be used selectively in conjunction with early ambulation.
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17
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Park JH, Lee KE, Yu YM, Park YH, Choi SA. Incidence and Risk Factors for Venous Thromboembolism After Spine Surgery in Korean Patients. World Neurosurg 2019; 128:e289-e307. [PMID: 31028984 DOI: 10.1016/j.wneu.2019.04.140] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Data regarding the incidence of venous thromboembolism (VTE) after spine surgery are scarce. Identifying ideal candidates for pharmacologic thromboprophylaxis and balancing the risk of thromboembolic complications against the risk of permanent neurologic deficits from a spinal epidural hematoma (SEH) are difficult. Even guidelines cannot suggest the standard of thromboprophylaxis. OBJECTIVES This study aimed to identify the incidence of and risk factors for VTE after spine surgery in the Korean population. In addition, the rate of pharmacoprophylaxis and the incidence of SEH after spine surgery were analyzed. METHODS The study cohort was generated by extracting patients with disease codes of spine surgery and VTE from the Health Insurance Review & Assessment Service National Inpatient Sample in 2014. After analyzing the incidence of VTE after spine surgery, a univariate comparison was performed to examine the possible relationship between the incidence of VTE and the independent variable. Variables found to be significant were included in a multivariable analysis model for further analysis. RESULTS The incidence of VTE was 2.09% among all 21,261 patients who had spine surgery, and prophylaxis was applied to 7.89% of all patients who had spine surgery. Comorbidities and surgery-related risk factors were venous disease, cancer, respiratory disease, prolonged surgery hours, and increased total blood loss. Hospital-related risk factors were the location and hospital size. CONCLUSIONS On the basis of the incidence of VTE and the risk factors, more active prophylaxis is suggested for patients in the Korean population who undergo spine surgery.
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Affiliation(s)
- Ji Hyun Park
- College of Pharmacy, Korea University, Sejong-si, Republic of Korea
| | - Kyung Eun Lee
- College of Pharmacy, Chungbuk National University, Yeonje-ri, Osong-eup, Heungdeok-gu, Cheongju-si, Republic of Korea
| | - Yun Mi Yu
- College of Pharmacy, Yonsei University, Incheon, Yeonsu-gu, Republic of Korea
| | | | - Soo An Choi
- College of Pharmacy, Korea University, Sejong-si, Republic of Korea.
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Cloney MB, Goergen J, Hopkins BS, Dhillon ES, Dahdaleh NS. Factors associated with venous thromboembolic events following ICU admission in patients undergoing spinal surgery: an analysis of 1269 consecutive patients. J Neurosurg Spine 2019; 30:99-105. [PMID: 30485211 DOI: 10.3171/2018.5.spine171027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 05/25/2018] [Indexed: 11/06/2022]
Abstract
In BriefIn a retrospective study the authors examined 1269 patients who underwent spinal surgery and were admitted to the intensive care unit (ICU) and identified factors that are associated with venous thromboembolic events (VTEs) in this "high risk" group. Amongst these high-risk factors were: surgeries longer than 4 hours, comorbid disease, patients needing an osteotomy, and patients undergoing spinal stabilization for fractures. Identification of factors that can be optimized prior to surgery will decrease the rates of VTE.
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20
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Natsumeda M, Uzuka T, Watanabe J, Fukuda M, Akaiwa Y, Hanzawa K, Okada M, Oishi M, Fujii Y. High Incidence of Deep Vein Thrombosis in the Perioperative Period of Neurosurgical Patients. World Neurosurg 2018; 112:e103-e112. [DOI: 10.1016/j.wneu.2017.12.139] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
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Risk of post-operative venous thromboembolism in patients with meningioma. J Neurooncol 2018; 138:401-406. [DOI: 10.1007/s11060-018-2810-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 02/18/2018] [Indexed: 12/21/2022]
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Dhillon ES, Khanna R, Cloney M, Roberts H, Cybulski GR, Koski TR, Smith ZA, Dahdaleh NS. Timing and risks of chemoprophylaxis after spinal surgery: a single-center experience with 6869 consecutive patients. J Neurosurg Spine 2017; 27:681-693. [DOI: 10.3171/2017.3.spine161076] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEVenous thromboembolism (VTE) after spinal surgery is a major cause of morbidity, but chemoprophylactic anticoagulation can prevent it. However, there is variability in the timing and use of chemoprophylactic anticoagulation after spine surgery, particularly given surgeons’ concerns for spinal epidural hematomas. The goal of this study was to provide insight into the safety, efficacy, and timing of anticoagulation therapy after spinal surgery.METHODSThe authors retrospectively examined records from 6869 consecutive spinal surgeries performed in their departments at Northwestern University. Data on patient demographics, surgery, hospital course, timing of chemoprophylaxis, and complications, including deep venous thrombosis (DVT), pulmonary embolism (PE), and spinal epidural hematomas requiring evacuation, were collected. Data from the patients who received chemoprophylaxis (n = 1904) were compared with those of patients who did not (n = 4965). The timing of chemoprophylaxis, the rate of VTEs, and the incidence of spinal epidural hematomas were analyzed.RESULTSThe chemoprophylaxis group had more risk factors, including greater age (59.70 vs 51.86 years, respectively; p < 0.001), longer surgery (278.59 vs 145.66 minutes, respectively; p < 0.001), higher estimated blood loss (995 vs 448 ml, respectively; p < 0.001), more comorbid diagnoses (2.69 vs 1.89, respectively; p < 0.001), history of VTE (5.8% vs 2.1%, respectively; p < 0.001), and a higher number were undergoing fusion surgery (46.1% vs 24.7%, respectively; p < 0.001). The prevalence of VTE was higher in the chemoprophylaxis group (3.62% vs 2.03%, respectively; p < 0.001). The median time to VTE occurrence was shorter in the nonchemoprophylaxis group (3.6 vs 6.8 days, respectively; p = 0.0003, log-rank test; hazard ratio 0.685 [0.505–0.926]), and the peak prevalence of VTE occurred in the first 3 postoperative days in the nonchemoprophylaxis group. The average time of initiation of chemoprophylaxis was 1.46 days after surgery. The rates of epidural hematoma were 0.20% (n = 4) in the chemoprophylaxis group and 0.18% (n = 9) in the nonchemoprophylaxis group (p = 0.622).CONCLUSIONSThe risks of spinal epidural hematoma among patients who receive chemoprophylaxis and those who do not are low and equivalent. Administering anticoagulation therapy from 1 day before to 3 days after surgery is safe for patients at high risk for VTE.
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Affiliation(s)
- Ekamjeet S. Dhillon
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine; and
| | - Ryan Khanna
- 2Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Michael Cloney
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine; and
| | - Helena Roberts
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine; and
| | - George R. Cybulski
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine; and
| | - Tyler R. Koski
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine; and
| | - Zachary A. Smith
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine; and
| | - Nader S. Dahdaleh
- 1Department of Neurological Surgery, Northwestern University Feinberg School of Medicine; and
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Ganau M, Prisco L, Cebula H, Todeschi J, Abid H, Ligarotti G, Pop R, Proust F, Chibbaro S. Risk of Deep vein thrombosis in neurosurgery: State of the art on prophylaxis protocols and best clinical practices. J Clin Neurosci 2017; 45:60-66. [PMID: 28890040 DOI: 10.1016/j.jocn.2017.08.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/10/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To analytically discuss some protocols in Deep vein thrombosis (DVT)/pulmonary Embolism (PE) prophylaxis currently use in Neurosurgical Departments around the world. DATA SOURCES Analysis of the prophylaxis protocols in the English literature: An analytical and narrative review of literature concerning DVT prophylaxis protocols in Neurosurgery have been conducted by a PubMed search (back to 1978). DATA EXTRACTION 80 abstracts were reviewed, and 74 articles were extracted. DATA ANALYSIS The majority of DVT seems to develop within the first week after a neurosurgical procedure, and a linear correlation between the duration of surgery and DVT occurrence has been highlighted. The incidence of DVT seems greater for cranial (7.7%) than spinal procedures (1.5%). Although intermittent pneumatic compression (IPC) devices provided adequate reduction of DVT/PE in some cranial and combined cranial/spinal series, low-dose subcutaneous unfractionated heparin (UFH) or low molecular-weight heparin (LMWH) further reduced the incidence, not always of DVT, but of PE. Nevertheless, low-dose heparin-based prophylaxis in cranial and spinal series risks minor and major postoperative haemorrhages: 2-4% in cranial series, 3.4% minor and 3.4% major haemorrhages in combined cranial/spinal series, and a 0.7% incidence of major/minor haemorrhages in spinal series. CONCLUSION This analysis showed that currently most of the articles are represented by case series and case reports. As long as clear guidelines will not be defined and universally applied to this diverse group of patients, any prophylaxis for DVT and PE should be tailored to the individual patient with cautious assessment of benefits versus risks.
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Affiliation(s)
- Mario Ganau
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Lara Prisco
- Nuffield Department of Clinical Neuroscience, Oxford University Hospitals, UK
| | - Helene Cebula
- Dept of Neurosurgery, Strasbourg University Hospital, France
| | - Julien Todeschi
- Dept of Neurosurgery, Strasbourg University Hospital, France.
| | - Houssem Abid
- Dept of Neurosurgery, Strasbourg University Hospital, France
| | | | - Raoul Pop
- Dept of Neurosurgery, Strasbourg University Hospital, France
| | - Francois Proust
- Dept of Neurosurgery, Strasbourg University Hospital, France
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Wang X, Zhou YC, Zhu WD, Sun Y, Fu P, Lei DQ, Zhao HY. The risk of postoperative hemorrhage and efficacy of heparin for preventing deep vein thrombosis and pulmonary embolism in adult patients undergoing neurosurgery: a systematic review and meta-analysis. J Investig Med 2017; 65:1136-1146. [PMID: 28747317 DOI: 10.1136/jim-2016-000235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2017] [Indexed: 12/21/2022]
Abstract
The aim of this meta-analysis was to examine the risk of postoperative bleeding and efficacy of heparin for preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) in adult patients undergoing neurosurgery. MEDLINE, Cochrane, and EMBASE databases were searched until October 31, 2016, for randomized controlled trials (RCTs) and non-randomized comparative studies that assessed the rates of postoperative hemorrhage, DVT, PE, and mortality in adult patients undergoing neurosurgery. Nine eligible studies (five RCTs, four retrospective studies) including 874 patients treated with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) and 1033 patients in control group (placebo with or without compression device) were analyzed. The overall analysis revealed that there was an increase in the risk of postoperative hemorrhage in patients who received heparin (pooled OR 1.66, 95% CI 1.01 to 2.72, p=0.046) compared with no treatment group. The risk of postoperative hemorrhage was more significant if only RCTs were included in analysis. Heparin prophylaxis was associated with a decrease in the risk of DVT (pooled OR 0.48, 95% CI 0.36 to 0.65, p<0.001) and PE (pooled OR 0.25, 95% CI 0.09 to 0.73, p=0.011) but it did not affect the rate of mortality. In conclusion, heparin increased the rate of postoperative bleeding, decreased the risk of DVT, PE and venous thromboembolic event (VTE) but it did not affect the mortality of patients undergoing neurosurgery. For the heparin prophylaxis, the trade-off between the risk of postoperative bleeding and benefit of prophylaxis against VTEs requires further investigation.
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Affiliation(s)
- Xuan Wang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ying-Chun Zhou
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wen-De Zhu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Sun
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Fu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - De-Qiang Lei
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong-Yang Zhao
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Epstein NE. 24-48 hour preoperative "surveillance" lower extremity venous Doppler's: Aren't they worthwhile prior to spine surgery? Surg Neurol Int 2016; 7:S1075-S1079. [PMID: 28144488 PMCID: PMC5234293 DOI: 10.4103/2152-7806.196763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 10/12/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Most previous studies focused on the utility of Doppler surveillance to determine the incidence of deep venous thrombosis (DVT) following spine surgery. Here, we utilized Doppler surveillance to assess the frequency of DVT prior to spine surgery. METHODS We asked, how often do patients exhibit preoperative DVT? To answer this, for over a 7-month period, bilateral lower extremity venous Doppler's were prospectively obtained 24-48 hours prior to a variety of spinal operations among 45 patients. This did not include an analysis of postoperative venous Doppler's/incidence of pulmonary embolism for these patients. RESULTS Of the 45 patients, 3 (6.7%) exhibited preoperative positive/abnormal venous duplex studies (unilaterally) that led to cancellation of spinal surgery. One patient, a 56-year-old female, with a C6-C7 cervical disc, demonstrated a proximal right lower extremity DVT; she required full-dose anticoagulation and her surgery was cancelled. In two cases, a 42-year-old female and a 55-year-old male, exhibited DVT in the right posterior tibial and left peroneal veins respectively; both operations were cancelled, and they were placed on anticoagulants by their internists. CONCLUSIONS Over a 7-month period, prospective "surveillance Dopplers" of both lower extremities obtained 24-48 hours prior to spinal surgery documented 3 (6.7%) positive studies out of a series of 45 patients. One instance of DVT was proximal (e.g. femoral in local) whereas 2 were distal. These data showed that preoperative surveillance Doppler of both lower extremities was "worthwhile." However, performing these studies earlier than 24-48 hrs prior to surgery would help avoid last minute cancellations.
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Affiliation(s)
- Nancy E Epstein
- Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, New York - 11501, USA
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Prophylaxis of Venous Thrombosis in Neurocritical Care Patients: An Evidence-Based Guideline: A Statement for Healthcare Professionals from the Neurocritical Care Society. Neurocrit Care 2016; 24:47-60. [PMID: 26646118 DOI: 10.1007/s12028-015-0221-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The risk of death from venous thromboembolism (VTE) is high in intensive care unit patients with neurological diagnoses. This is due to an increased risk of venous stasis secondary to paralysis as well as an increased prevalence of underlying pathologies that cause endothelial activation and create an increased risk of embolus formation. In many of these diseases, there is an associated risk from bleeding because of standard VTE prophylaxis. There is a paucity of prospective studies examining different VTE prophylaxis strategies in the neurologically ill. The lack of a solid evidentiary base has posed challenges for the establishment of consistent and evidence-based clinical practice standards. In response to this need for guidance, the Neurocritical Care Society set out to develop and evidence-based guideline using GRADE to safely reduce VTE and its associated complications.
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Urbankova J, Quiroz R, Goldhaber SZ. Intermittent pneumatic compression and deep vein thrombosis prevention in postoperative patients. Phlebology 2016. [DOI: 10.1258/026835506778243031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
High incidence of venous thromboembolism (VTE) makes prophylaxis, screening and treatment extremely important. Both pharmacological and mechanical techniques can be used to reduce the risk of deep vein thrombosis (DVT). Mechanical methods have been studied much less intensively than pharmacological options. The principal mechanical methods of prophylaxis are graduated compression stockings and intemittent pneumatic compression devices. We conducted a meta-analysis of all randomized controlled trials to determine the effectiveness of intermittent pneumatic compression (IPC) devices in the preventon of DVT in post-surgical patients. The results of this analysis indicate that IPC devices reduced the risk of DVT by 60% when compared with patients with no mechanical or pharmacological prophylaxis. Contemporary randomized trials should be undertaken to test the utility of IPC in medcal patients as well as combined pharmacological plus IPC prophylaxis in both medical patients.
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Affiliation(s)
- J Urbankova
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - R Quiroz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - S Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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Venous thromboembolism prophylaxis in brain tumor patients undergoing craniotomy: a meta-analysis. J Neurooncol 2016; 130:561-570. [DOI: 10.1007/s11060-016-2259-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 08/27/2016] [Indexed: 10/21/2022]
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Raikundalia MD, Pines MJ, Svider PF, Baredes S, Folbe AJ, Liu JK, Eloy JA. Characterization of transsphenoidal complications in patients with acromegaly: an analysis of inpatient data in the United States from 2002 to 2010. Int Forum Allergy Rhinol 2015; 5:417-22. [DOI: 10.1002/alr.21498] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 12/23/2014] [Accepted: 01/01/2015] [Indexed: 12/15/2022]
Affiliation(s)
- Milap D. Raikundalia
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Newark NJ
| | - Morgan J. Pines
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Newark NJ
| | - Peter F. Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine; Detroit MI
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Newark NJ
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School; Newark NJ
| | - Adam J. Folbe
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine; Detroit MI
- Department of Neurosurgery, Wayne State University School of Medicine; Detroit MI
| | - James K. Liu
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Newark NJ
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School; Newark NJ
- Department of Neurological Surgery, Rutgers New Jersey Medical School; Newark NJ
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School; Newark NJ
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School; Newark NJ
- Department of Neurological Surgery, Rutgers New Jersey Medical School; Newark NJ
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Development of venous thromboembolism (VTE) in patients undergoing surgery for brain tumors: Results from a single center over a 10year period. J Clin Neurosci 2015; 22:519-25. [DOI: 10.1016/j.jocn.2014.10.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 10/01/2014] [Indexed: 11/30/2022]
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Hamidi S, Riazi M. Incidence of venous thromboembolic complications in instrumental spinal surgeries with preoperative chemoprophylaxis. J Korean Neurosurg Soc 2015; 57:114-8. [PMID: 25733992 PMCID: PMC4345188 DOI: 10.3340/jkns.2015.57.2.114] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 10/16/2014] [Accepted: 10/17/2014] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) after spinal surgery affects a patients' postoperative recovery and also carries a mortality risk. Some studies recommended chemical prophylaxis for high-risk patients and for those after complex spinal surgeries. However, chemoprophylaxis for VTE in spinal surgery is underemployed and there is no agreement on the use of VTE prophylaxis in spinal surgery. The aim of this study was to document the incidence of VTE after an elective instrumental spinal surgery, among those receiving preoperative chemoprophylaxis as compared with patients who did not receive it. METHODS This study was carried out on eighty-nine patients allocated randomly to receive either low molecular weight heparin (LMWH) or no prophylaxis before elective instrumental spinal surgery. All patients received postoperative compression stockings. A compression Doppler ultrasonography was performed for all patients to detect postoperative deep vein thrombosis. In addition, further imaging studies were performed for patients suspected of VTE. RESULTS Three (3.3%) patients were diagnosed with VTE. One of them had received preoperative chemoprophylaxis. There were no significant difference in incidence of VTE between the two groups (p>0.95; 95% confidence interval, 0.06-8.7). Laterality of gender and postsurgical recumbence duration were all independent predictors of VTE (p=0.01 and p<0.001, respectively). CONCLUSION The difference in the incidence of thromboembolic complications between the two groups was not significant. Moreover, we found that preoperative prophylactic LMWH injection has no major bleeding complications altering postoperative course; still, the issue concerning the initiation time of chemoprophylaxis in spinal surgery remains unclear.
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Affiliation(s)
- Saeed Hamidi
- Division of Neurosurgery, Department of Surgery, Bou-Ali Medical-Educational & Clinical Center, Tehran Medical Science Branch, Islamic Azad University, Tehran, Iran
| | - Mahdieh Riazi
- Medical Science Research Center, Tehran Medical Science Branch, Islamic Azad University, Tehran, Iran
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[Thromboprophylaxis and platelet aggregation inhibitors in spinal surgery: perioperative management]. DER ORTHOPADE 2014; 43:833-40. [PMID: 25116247 DOI: 10.1007/s00132-014-2319-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The perioperative use of anticoagulants (AC) and platelet aggregation inhibitors (PAI) in the field of spinal surgery suggests an increased rate of epidural bleeding. However, evidence is lacking and these medications are most often indispensable in the prevention of thromboembolic complications. Comprehensive recommendations for the correct use of AC and PAI are lacking. OBJECTIVE The aim of this study was an analysis of the current situation with regards to the use of AC and PAI in spinal surgery and development of new recommendations. MATERIAL AND METHODS Two independent surveys on the perioperative use of AC and PAI were obtained from centers for spinal surgery in Germany. The study obtained information on the perioperative use of AC and PAI, risk assessment of thromboembolic and hemorrhagic events as well as on the type and extent of the substance groups used. RESULTS Almost the entire patient collective (98%) received perioperative low molecular weight heparin. In 64% the medical prophylaxis was started before surgery and in 36% after surgery. The period of prophylaxis was determined arbitrarily. Approximately 40% of interviewees employed paravertebral infiltration and 19% injected into the epidural space in patients on PAI medication. Open spinal canal surgery was performed in 30% of PAI medicated patients and closed spinal canal surgery was executed in 40%. The risk assessment of PAI differed significantly between aspirin and receptor blocker medication as well as dual administration of PAI. DISCUSSION The use of AC and PAI in spinal surgery in Germany is very heterogeneous and large deviations from the guidelines frequently occurred. Therefore, there is a strong need for further studies to accurately assess the perioperative use of AC and PAI and to formulate precise recommendations.
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Patient-based and surgical characteristics associated with the acute development of deep venous thrombosis and pulmonary embolism after spine surgery. Spine (Phila Pa 1976) 2013; 38:1892-8. [PMID: 23778367 DOI: 10.1097/brs.0b013e31829fc3a0] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospectively collected data set. OBJECTIVE Identify the incidence of, and risk factors for, deep venous thrombosis (DVT) and pulmonary embolism (PE) after spine surgery. SUMMARY OF BACKGROUND DATA Determination of ideal candidates for chemoprophylaxis after spine surgery is limited by the state of the literature, including incomplete understanding regarding the incidence of DVT and PE, as well as an inability to quantify specific risk factors among patients. METHODS The 2005 to 2011 data set of the National Surgical Quality Improvement Program was queried to identify all individuals having undergone spine surgery. Demographic data, medical comorbidities, surgical characteristics, and the presence of DVT, PE, and/or mortality were abstracted for all individuals meeting inclusion criteria. Unadjusted univariate analysis was performed to identify variables that were potentially associated with the development of DVT or PE after surgery. A multivariate logistic regression test, controlling for other factors present in the model, was subsequently performed. Predictor variables that maintained significance after multivariate testing were considered influential in the development of DVT and/or PE. RESULTS There were 27,730 patients who received spine procedures in this cohort. The average age was 56.4 (± 15.1) years. Lumbar spine procedures made up 61% of interventions. Death occurred in 87 instances (0.3%). The venous thromboembolic rate was 1%, with 206 individuals (0.7%) sustaining DVT and 113 (0.4%) developing a PE. Body mass index 40 and greater, age 80 years and older, operative time exceeding 261 minutes, and American Society of Anesthesiologists classification 3 or higher were identified as significant independent predictors of DVT, whereas body mass index 40 and greater, operative time exceeding 261 minutes, and male sex were associated with the development of PE. CONCLUSION Multiple independent risk factors for the development of DVT and/or PE after spine surgery were identified. Patients with these characteristics may require additional counseling, procedural modification, or prophylaxis against venous thromboembolic events.
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Meng XL, Zhao H, Su QJ, Hai Y. Acute pulmonary embolism following adolescent idiopathic scoliosis correction surgery: case report and review of literature. J Int Med Res 2013; 41:1759-67. [PMID: 24051020 DOI: 10.1177/0300060513501752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Pulmonary embolism is a significant complication of surgery. This report presents a case of suspected fatal postoperative acute pulmonary embolism following posterior correction surgery in a 16-year-old female with idiopathic scoliosis. The patient presented with a suspected pulmonary embolism 2 h postoperatively. She lost consciousness quickly, and cardiac respiratory arrest occurred. Cardiopulmonary resuscitation was started immediately. The patient was stabilized but underwent a further suspected pulmonary embolism the following day. Cardiopulmonary resuscitation was performed again, but she lost consciousness and respirator support was required. At 40 days after surgery, a computed tomography scan revealed an area of necrotic brain tissue near the lateral cerebral ventricle. The patient remained in a comatose state for 16 months, after which active management was withdrawn. This case reminds us to be alert to potentially fatal postoperative pulmonary embolism in young patients without any risk factors for thrombosis.
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Affiliation(s)
- Xiang Long Meng
- Department of Orthopaedics, Chao Yang Hospital, Capital Medical University, Beijing, China
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35
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Epstein NE. How much medicine do spine surgeons need to know to better select and care for patients? Surg Neurol Int 2012; 3:S329-49. [PMID: 23248752 PMCID: PMC3520072 DOI: 10.4103/2152-7806.103866] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 08/13/2012] [Indexed: 12/13/2022] Open
Abstract
Background: Although we routinely utilize medical consultants for preoperative clearance and postoperative patient follow-up, we as spine surgeons need to know more medicine to better select and care for our patients. Methods: This study provides additional medical knowledge to facilitate surgeons’ “cross-talk” with medical colleagues who are concerned about how multiple comorbid risk factors affect their preoperative clearance, and impact patients’ postoperative outcomes. Results: Within 6 months of an acute myocardial infarction (MI), patients undergoing urological surgery encountered a 40% mortality rate: similar rates may likely apply to patients undergoing spinal surgery. Within 6 weeks to 2 months of placing uncoated cardiac, carotid, or other stents, endothelialization is typically complete; as anti-platelet therapy may often be discontinued, spinal surgery can then be more safely performed. Coated stents, however, usually require 6 months to 1 year for endothelialization to occur; thus spinal surgery is often delayed as anti-platelet therapy must typically be continued to avoid thrombotic complications (e.g., stroke/MI). Diabetes and morbid obesity both increase the risk of postoperative infection, and poor wound healing, while the latter increases the risk of phlebitis/pulmonary embolism. Both hypercoagluation and hypocoagulation syndromes may require special preoperative testing/medications and/or transfusions of specific hematological factors. Pulmonary disease, neurological disorders, and major psychiatric pathology may also require further evaluations/therapy, and may even preclude successful surgical intervention. Conclusions: Although we as spinal surgeons utilize medical consultants for preoperative clearance and postoperative care, we need to know more medicine to better select and care for our patients.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurological Surgery, The Albert Einstein College of Medicine, Department of Neurosurgery, Bronx, New York, Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, New York, President, Long Island Neurosurgical Associates, PC, 410 Lakeville Rd Suite 204, New Hyde Park, New York, USA
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Aishima K, Yoshimoto Y. Screening strategy using sequential serum D-dimer assay for the detection and prevention of venous thromboembolism after elective brain tumor surgery. Br J Neurosurg 2012; 27:348-54. [PMID: 23131147 DOI: 10.3109/02688697.2012.737958] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a life-threatening complication in neurosurgical patients. This study retrospectively analyzed the effectiveness and safety of a screening strategy for the detection and prevention of VTE in patients undergoing elective brain tumor surgery. PATIENTS A total of 419 consecutive patients who underwent brain tumor surgery during 5 years were enrolled. At the midpoint of the study period, screening for VTE was introduced based on measurement of serum D-dimer level on the day after surgery and then once or twice every week. Anticoagulant therapy was started after the diagnosis of VTE. The two groups with (228 patients) and without (191 patients) screening were compared. RESULTS Most of the demographic and clinical characteristics were relatively well balanced in the groups. VTE was diagnosed in 23 (5.5%) patients overall; the rate was higher in the screening group (7.0%) than in the non-screening group (3.7%). Although the rate of VTE-related adverse events was lower in the screening group (1.3% vs. 2.6%), the rate of hemorrhagic complications was higher (2.2% vs. 0.5%). Multivariate analysis indicated that malignant histology and preoperative paresis were independent risk factors for the diagnosis of VTE. CONCLUSIONS Many VTE patients may not exhibit signs or symptoms, so screening using surrogate markers for VTE (D-dimer) may be useful in the early detection of asymptomatic VTE. However, most distal, deep venous thrombosis in isolation is not life-threatening, so the added efficacy of anticoagulant agents at this stage has to be weighed against the risks of hemorrhagic complications, especially in the early postoperative period.
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Affiliation(s)
- Kaoru Aishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Japan
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Masuda K, Chikuda H, Yasunaga H, Hara N, Horiguchi H, Matsuda S, Takeshita K, Kawaguchi H, Nakamura K. Factors affecting the occurrence of pulmonary embolism after spinal surgery: data from the national administrative database in Japan. Spine J 2012; 12:1029-34. [PMID: 23158967 DOI: 10.1016/j.spinee.2012.10.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 09/05/2012] [Accepted: 10/13/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite potentially devastating consequences, pulmonary embolism (PE) in patients undergoing spinal surgery remains poorly understood. To the best of our knowledge, few large studies have examined the prevalence and risk factors of PE after spinal surgery. PURPOSE To investigate the prevalence of symptomatic PE in patients undergoing elective spinal surgery and to identify clinical variables associated with the occurrence of postoperative PE. STUDY DESIGN A retrospective analysis of data abstracted from the diagnosis procedure combination (DPC) database, a nationally representative database in Japan. PATIENT SAMPLE We included all patients with a diagnosis of spinal canal stenosis, disc herniation, spondylosis, spondylolisthesis, trauma, metastatic tumor, or infection who underwent spinal surgery between July 1 and December 31 of 2007 and 2008, respectively. OUTCOME MEASURES The primary end point was defined as the occurrence of postoperative PE during hospitalization. The secondary end point was in-hospital death after postoperative PE. METHODS We analyzed the association between the occurrence of postoperative PE and clinical variables recorded in the DPC database, including age, sex, comorbidities, location of surgery, primary diagnosis, anterior/posterior approach, use of instrumentation, and duration of anesthesia. RESULTS A total of 47,743 patients were identified. Of these, 50 (0.10%) developed PE and four died as a result of PE. Logistic regression analyses revealed that occurrence of PE was associated with older age (70 years or older; odds ratio [OR], 3.15; 95% confidence interval [CI], 1.15-8.69; p=.026) and longer anesthesia time (more than 360 minutes; OR, 2.19; 95% CI, 0.88-5.44; p=.092). Patients with trauma were significantly more likely to have a PE than those with spinal canal stenosis (0.27% vs. 0.09%; OR, 2.86; 95% CI, 1.14-7.18; p=.026). CONCLUSIONS This retrospective analysis of a nationally representative database identified older age, longer anesthesia time, and spinal trauma as risk factors for increased incidence of postoperative PE. Surgeons should be aware of the increased risk of postoperative PE in these subgroups of patients.
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Affiliation(s)
- Kazuhiro Masuda
- Department of Orthopedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Tsang KKT, Whitfield PC. Traumatic brain injury: review of current management strategies. Br J Oral Maxillofac Surg 2011; 50:298-308. [PMID: 21530028 DOI: 10.1016/j.bjoms.2011.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 03/17/2011] [Indexed: 11/26/2022]
Abstract
Head injury is a common condition with a high morbidity and mortality. Serious intracranial haematomas require early recognition and evacuation to maximise chances of independent outcomes. Recent organisational changes have promoted the development of trauma units and major trauma centres where patients can go through triage and be managed in an appropriate environment, and the development of management pathways in intensive treatment units has resulted in improvements in the outcome of traumatic brain injuries. Evidence for the treatment of cerebral perfusion pressure, and management of hyperventilation, osmotherapy, tracheostomy, and leakage of cerebrospinal fluid (CSF) has accumulated during the last decade and is important in the management of patients in all clinical settings. Since head injury is commonly associated with maxillofacial injuries, this review will be relevant to all who deal with this aspect of trauma.
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Affiliation(s)
- Kevin King-Tin Tsang
- Derriford Hospital, Department of Neurosurgery, Derriford Road, Plymouth PL6 8DH, United Kingdom.
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Perioperative pulmonary embolism: diagnosis and anesthetic management. J Clin Anesth 2011; 23:153-65. [DOI: 10.1016/j.jclinane.2010.06.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 06/18/2010] [Accepted: 06/29/2010] [Indexed: 12/17/2022]
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40
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Kim HJ, Walcott-Sapp S, Adler RS, Pavlov H, Boachie-Adjei O, Westrich GH. Thromboembolic Complications Following Spine Surgery Assessed with Spiral CT Scans: DVT/PE Following Spine Surgery. HSS J 2011; 7:37-40. [PMID: 22294955 PMCID: PMC3026105 DOI: 10.1007/s11420-010-9179-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 06/29/2010] [Indexed: 02/07/2023]
Abstract
Spine surgery is associated with a significant risk of postoperative pulmonary embolism (PE) and/or deep vein thrombosis (DVT). The goal of this study was to determine which symptoms and risk factors were associated with spiral CT scans positive for PE and/or DVT in the postoperative spine surgery patient. We conducted a retrospective review of all spine patients who underwent a postoperative CT to rule out PE during the period of March 2004-February 2006. The type of surgical procedure, risk factors, symptoms prompting scan ordering, anticoagulation, and treatment were recorded. Logistic regression models were used to determine significant predictors of a positive CT in this patient population. Of the 3,331 patients that had spine surgery during the study period, 130 (3.9%) had a spiral CT scan to rule out PE and/or proximal DVT. Thirty-three of the 130 (25.4%) CT scans were positive for PE only, five (3.8%) for PE and DVT, and three (2.3%) for DVT only. Only 24.5% (32) patients had risk factors for thromboembolic disease, and of these, a history of PE and/or DVT was the only significant risk factor for a positive scan (p = 0.03). No presenting symptoms or demographic variables were noted to have a significant association with PE and/or DVT. The type of surgical procedure (i.e., anterior, posterior, and percutaneous) was not associated with an increased risk for PE and/or DVT. Patients who are undergoing spine surgery with a history of thromboembolic disease should be carefully monitored postoperatively and may benefit from more aggressive prophylaxis.
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Affiliation(s)
- Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Sarah Walcott-Sapp
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Ronald S. Adler
- Department of Radiology, Hospital for Special Surgery, New York, NY USA ,Weill Cornell Medical College, New York, NY USA
| | - Helene Pavlov
- Department of Radiology, Hospital for Special Surgery, New York, NY USA ,Weill Cornell Medical College, New York, NY USA
| | - Oheneba Boachie-Adjei
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Weill Cornell Medical College, New York, NY USA
| | - Geoffrey H. Westrich
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Weill Cornell Medical College, New York, NY USA
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Martin MJ, Blair KS, Curry TK, Singh N. Vena Cava Filters: Current Concepts and Controversies for the Surgeon. Curr Probl Surg 2010; 47:524-618. [DOI: 10.1067/j.cpsurg.2010.03.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Gerlach R, Krause M, Seifert V, Goerlinger K. Hemostatic and hemorrhagic problems in neurosurgical patients. Acta Neurochir (Wien) 2009; 151:873-900; discussion 900. [PMID: 19557305 DOI: 10.1007/s00701-009-0409-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 10/22/2008] [Indexed: 01/10/2023]
Abstract
BACKGROUND Abnormalities of the hemostasis can lead to hemorrhage, and on the other hand to thrombosis. Intracranial neoplasms, complex surgical procedures, and head injury have a specific impact on coagulation and fibrinolysis. Moreover, the number of neurosurgical patients on medication (which interferes with platelet function and/or the coagulation systems) has increased over the past years. METHOD The objective of this review is to recall common hemostatic disorders in neurosurgical patients on the basis of the "new concept of hemostasis". Therefore the pertinent literature was searched to provide a structured and up to date manuscript about hemostasis in Neurosurgery. FINDINGS According to recent scientific publications abnormalities of the coagulation system are discussed. Pathophysiological background and the rational for specific (cost)-effective perioperative hemostatic therapy is provided. CONCLUSIONS Perturbations of hemostasis can be multifactorial and maybe encountered in the daily practice of neurosurgery. Early diagnosis and specific treatment is the prerequisite for successful treatment and good patients outcome.
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Affiliation(s)
- Ruediger Gerlach
- Department of Neurosurgery, Johann Wolfgang Goethe University, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany.
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Estimating the Applicability of Wound Care Randomized Controlled Trials to General Wound-Care Populations by Estimating the Percentage of Individuals Excluded from a Typical Wound-Care Population in Such Trials. Adv Skin Wound Care 2009; 22:316-24. [DOI: 10.1097/01.asw.0000305486.06358.e0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Senft C, Schuster T, Forster MT, Seifert V, Gerlach R. Management and outcome of patients with acute traumatic subdural hematomas and pre-injury oral anticoagulation therapy. Neurol Res 2009; 31:1012-8. [PMID: 19570326 DOI: 10.1179/174313209x409034] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Acute subdural hematomas (aSDHs) are found in up to one-third of patients with severe traumatic brain injury and are associated with an unfavorable outcome in the majority of cases. Mortality ranges between 40 and 60%, but was reported to be even higher in patients undergoing oral anticoagulation therapy (OAT) at the time of injury. The objective of this study is to specifically report on the peri-operative management and outcome of patients with aSDH and pre-injury OAT. MATERIAL AND METHODS From June 2002 to June 2006, all patients with OAT who underwent surgical treatment of aSDH were retrospectively analysed. Results of pre-operative blood tests, the peri-operative and surgical management and the clinical courses were assessed. Patient outcome is reported according to the Glasgow Outcome Scale (GOS) at 6 months. RESULTS Eleven (10.3%) out of 107 patients with aSDH were on OAT. Patients with OAT were significantly older than patients without OAT (72.4 +/- 9.3 versus 59.9 +/- 17.5 years; p<0.05, Mann-Whitney U-test). Intensity of head trauma was moderate in four and severe in seven patients with a median pre-operative Glasgow Coma Scale (GCS) of 8. Median pre-treatment prothrombin time and international normalized ratio were 23% (range: 10-65%) and 3.3 (range: 1.5-10.6), respectively. Replacement therapy consisted of administration of prothrombin complex concentrates, vitamin K and FFP (fresh frozen plasma). In four patients, antithrombin was additionally given to prevent disseminated intravascular coagulation. Surgical treatment consisted of craniotomy (n=10) or craniectomy (n=1) and hematoma evacuation with intracranial pressure probe placement. Low molecular weight heparin was administered as pharmacological prophylaxis of thrombembolic events in an increasing dose post-operatively. At 6 months, six out of 11 patients survived with a median GOS of 4. All-cause mortality was 45.5%. A pre-operative GCS of < or = 8 was not associated with an increased risk of mortality (p>0.5, Fisher's exact test). No relevant rebleedings or thrombembolic complications were observed. The mortality rate of patients who did not undergo OAT was 50%. CONCLUSION A large number of patients with aSDH are on pre-injury OAT. Specific replacement therapy facilitates successful clot evacuation without bleeding complications. The overall outcome of these patients does not seem to differ from historical cohorts with aSDH without OAT, but a large prospective multicenter study is warranted to answer that question.
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Affiliation(s)
- Christian Senft
- Department of Neurosurgery, Goethe University, Frankfurt, Germany.
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Kim KS, Brophy GM. Symptomatic venous thromboembolism: incidence and risk factors in patients with spontaneous or traumatic intracranial hemorrhage. Neurocrit Care 2009; 11:28-33. [PMID: 19238588 DOI: 10.1007/s12028-009-9201-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 02/04/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objectives of this study are to determine the incidence of symptomatic venous thromboembolism (VTE) in neurosurgery intensive care unit (NSICU) patients with spontaneous or traumatic intracranial hemorrhage and to identify the common VTE risk factors by injury type. METHODS This retrospective, single-center cohort study included adult patients admitted to the NSICU between January 2001 and July 2004 with a primary diagnosis of subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), or traumatic brain injury (TBI). Patients and VTE events were identified using ICD-9 codes. All patients received low-dose unfractionated heparin or enoxaparin and intermittent pneumatic compression device. Descriptive statistics were used to describe patient characteristics. RESULTS The overall incidence of symptomatic VTE was 3.8% (n = 1195). The incidence of VTE was 6.7% in SAH patients (n = 179), 2.9% in ICH patients (n = 516), and 3.8% in TBI patients (n = 500). The most commonly identified risk factors in the three groups were: greater than 40 years of age, immobility due to paresis or restrictions for mechanical ventilation, presumed infection, and presence of indwelling central venous catheter. There was no objective evidence of intracranial bleeding associated with pharmacologic VTE prophylaxis in VTE patients. CONCLUSION This is the first study to determine symptomatic VTE incidence and to identify common risk factors by injury type in nontumor patients who are not routinely screened with venous duplex ultrasonography but receiving early IPC and LDUH. Further studies are needed to determine the overall incident of symptomatic and nonsymptomatic VTE and independent risk factors for VTE events in NSICU patients.
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Affiliation(s)
- Keri S Kim
- Department of Pharmacy Practice, University of Illinois Medical Center at Chicago, Chicago, IL, USA
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Selleng K, Lubenow LE, Greinacher A, Warkentin TE. Perioperative management of MYH9 hereditary macrothrombocytopenia (Fechtner syndrome). Eur J Haematol 2007; 79:263-8. [PMID: 17655694 DOI: 10.1111/j.1600-0609.2007.00913.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Hereditary thrombocytopenias characterized by mutations in the gene for non-muscle myosin heavy chain IIA (NMMHC-IIA) are known as MYH9-related hereditary macrothrombocytopenia, and include the May-Hegglin anomaly, Sebastian platelet syndrome, Fechtner syndrome, and Epstein syndrome. Despite the presence of thrombocytopenia, these patients often have only mild or non-bleeding phenotypes. A major risk for these patients can be inappropriate treatment with long-term corticosteroids or splenectomy for misdiagnosed chronic autoimmune thrombocytopenia, as well as inadequate peri- and postoperative management. METHODS Using the case of a 44-yr-old male with Fechtner syndrome (macrothrombocytopenia, leukocyte inclusions, sensorineural deafness, glomerulonephritis) who underwent neurosurgery for an intracerebral arteriovenous malformation, we describe current methods to diagnose hereditary MYH9-related macrothombocytopenia by analysis of the blood smear, immunofluorescence staining of the NMMHC-IIA in leucocytes, and by MYH9-gene sequencing. RESULTS Clusters of NMMHC-IIA in granulocytes and a R1165C mutation in the MYH9-gene in two macrothrombocytopenic family members confirmed the diagnosis of a MYH9-related disease. The patient had no bleeding diathesis by history or physical examination. Thus no perioperative prohemostatic pharmacologic therapies or transfusions were given, with only minimal bleeding observed. Postoperative antithrombotic thromboprophylaxis was not given because of anticipated enhanced risk for bleeding. However, the patient developed symptomatic pulmonary embolism on postoperative day 6, which was successfully managed with 8 months of anticoagulation. CONCLUSION MYH9-related hereditary macrothrombocytopenia does not necessarily protect against postoperative venous thromboembolism, and affected patients who do not evince bleeding diathesis should be considered for routine postoperative pharmacologic thromboprophylaxis.
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Affiliation(s)
- Kathleen Selleng
- Department of Transfusion Medicine and Immunology, Ernst-Moritz-Arndt University, Greifswald, Germany
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Morse K, Weight M, Molinari R. Extensive postoperative epidural hematoma after full anticoagulation: case report and review of the literature. J Spinal Cord Med 2007; 30:282-7. [PMID: 17684896 PMCID: PMC2031966 DOI: 10.1080/10790268.2007.11753938] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation. METHODS Case report. FINDINGS After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma. RESULTS Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy. CONCLUSIONS Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.
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Affiliation(s)
- Kenneth Morse
- University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
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Wen PY, Schiff D, Kesari S, Drappatz J, Gigas DC, Doherty L. Medical management of patients with brain tumors. J Neurooncol 2006; 80:313-32. [PMID: 16807780 DOI: 10.1007/s11060-006-9193-2] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 05/03/2006] [Indexed: 10/24/2022]
Abstract
The most common medical problems in brain tumor patients include the management of seizures, peritumoral edema, medication side effects, venous thromboembolism (VTE), fatigue and cognitive dysfunction. Despite their importance, there are relatively few studies specifically addressing these issues. There is increasing evidence that brain tumor patients who have not had a seizure do not benefit from prophylactic antiepileptic medications. Patients on corticosteroids are at greater risk of Pneumocystis jerovecii pneumonia and may benefit from prophylactic therapy. There is also growing evidence suggesting that anticoagulation may be more effective than inferior vena cava IVC) filtration devices for treating VTE in brain tumor patients and the risk of hemorrhage with anticoagulation is relatively small. Low-molecular weight heparin may be more effective than coumadin. Medications such as modafinil and methylphenidate have assumed an increasing role in the treatment of fatigue, while donepezil and memantine may be helpful with memory loss.
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Affiliation(s)
- Patrick Y Wen
- Division of Neuro-Oncology, Department of Neurology, Brigham and Women's Hospital and Center for Neuro-Oncology, Dana-Farber Brigham and Women's Cancer Center, SW430D, 44 Binney Street, Boston, MA 02115, USA.
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Lee J, Parsa AT, Ames CP, McCormick PC. Clinical management of intramedullary spinal ependymomas in adults. Neurosurg Clin N Am 2006; 17:21-7. [PMID: 16448904 DOI: 10.1016/j.nec.2005.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Janet Lee
- Department of Neurological Surgery, University of Utah, Salt Lake City, 30 N, 1900 E, RM 3B409, UT 84112, USA
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