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Greuter L, Rychen J, Chiappini A, Mariani L, Guzman R, Soleman J. Management of Patients undergoing Elective Craniotomy under Antiplatelet or Anticoagulation Therapy: An International Survey of Practice. J Neurol Surg A Cent Eur Neurosurg 2024; 85:246-253. [PMID: 37168014 DOI: 10.1055/s-0043-1767724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND The literature concerning the management of antiplatelet (AP) and anticoagulation (AC) medication in the perioperative phase of craniotomy remains scarce. The aim of this international survey was to investigate the current practice among neurosurgeons regarding their perioperative management of AP and AC medication. METHODS We distributed an online survey to neurosurgeons worldwide with questions concerning their perioperative practice with AP and AC medication in patients undergoing craniotomy. Descriptive statistics were performed. RESULTS A total of 130 replies were registered. The majority of responders practice neurosurgery in Europe (79%) or high-income countries (79%). Responders reported in 58.9 and 48.8% to have institutional guidelines for the perioperative management of AP and AC medication. Preoperative interruption time was reported heterogeneously for the different types of AP and AC medication with 40.4% of responders interrupting aspirin (ASA) for 4 to 6 days and 45.7% interrupting clopidogrel for 6 to 8 days. Around half of the responders considered ASA safe to be continued or resumed within 3 days for bypass (55%) or vascular (49%) surgery, but only few for skull base or other tumor craniotomies in general (14 and 26%, respectively). Three quarters of the responders (74%) did not consider AC safe to be continued or resumed early (within 3 days) for any kind of craniotomy. ASA was considered to have the lowest risk of bleeding. Nearly all responders (93%) agreed that more evidence is needed concerning AP and AC management in neurosurgery. CONCLUSION Worldwide, the perioperative management of AP and AC medication is very heterogeneous among neurosurgeons.
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Affiliation(s)
- Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Jonathan Rychen
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Alessio Chiappini
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Rychen J, Saemann A, Fingerlin T, Guzman R, Mariani L, Greuter L, Soleman J. Risks and benefits of continuation and discontinuation of aspirin in elective craniotomies: a systematic review and pooled-analysis. Acta Neurochir (Wien) 2023; 165:39-47. [PMID: 36376767 PMCID: PMC9840583 DOI: 10.1007/s00701-022-05416-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIM Discontinuation of aspirin (ASA) prior to elective craniotomies is common practice. However, patients treated with ASA for secondary prevention bear a higher risk for thromboembolic complications. Aim of this systematic review is to investigate the risks and benefits of perioperative continuation and discontinuation of ASA in elective craniotomies. METHODS PubMed and Embase databases were searched. Inclusion criteria were retro- and prospective studies, reporting hemorrhagic and thromboembolic complications in patients in whom ASA was either continued or discontinued perioperatively in elective craniotomies. We excluded shunt operations and emergency cases. The MINORS (Methodological index for non-randomized studies) score was used to quantify the methodological quality of the eligible studies. RESULTS Out of 523 publications, 7 met the eligibility criteria (cumulative cohort of 646 patients). The mean MINORS score for the comparative studies was 18.7/24 (± SD 2.07, range: 17-22) and 9/16 for the unique non-comparative study, indicating an overall weak methodological quality of the included studies. 57.1% of the patients underwent craniotomy for intra- and extra-axial tumor removal, 39.0% for bypass surgery and 3.9% for neurovascular lesions (other than bypass). In 31.0% of the cases, ASA was prescribed for primary and in 69.0% for secondary prevention. ASA was continued perioperatively in 61.8% and discontinued in 38.2% of the cases. The hemorrhagic complication rate was 3% (95% CI [0.01-0.05]) in the ASA continuation group (Con-Group) and 3% (95% CI [0.01-0.09]) in the discontinuation group (Disc-Group) (p = 0.9). The rate of thromboembolic events in the Con-Group was 3% (95% CI [0.01-0.06]) in comparison to 6% (95% CI [0.02-0.14]) in the Disc-Group (p = 0.1). CONCLUSION Perioperative continuation of ASA in elective craniotomies does not seem to be associated with an increased hemorrhagic risk. The potential beneficial effect of ASA continuation on thromboembolic events needs to be further investigated in patients under ASA for secondary prevention.
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Affiliation(s)
- Jonathan Rychen
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Attill Saemann
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Tamara Fingerlin
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
- Department of Clinical Studies, University Hospital of Basel, Basel, Switzerland.
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3
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Klein J, Mauck L, Schackert G, Pinzer T. Do statins reduce the rate of revision surgery after chronic subdural hematoma drain? Acta Neurochir (Wien) 2021; 163:1843-1848. [PMID: 34036461 PMCID: PMC8195925 DOI: 10.1007/s00701-021-04871-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/30/2021] [Indexed: 12/03/2022]
Abstract
BACKGROUND With chronic subdural hematoma (CSDH), surgery is the therapeutic mainstay for large or symptomatic cases. Statins are reported to be effective as the primary therapy of CSDH to obviate the need for surgery. However, the effect of statins on the postoperative course of CSDH is largely unclear. We therefore sought to determine whether statins reduce the rate of repeat surgery after CSDH drain. METHODS We performed an analysis of all patients who underwent surgery for CSDH at our institution between 2012 and 2018. The patients were separated into those who received statins as part of their previous medication (statin group) and those who did not (control group). The medical records were reviewed for repeat surgeries and complications. Additionally, patients or their relatives were contacted via phone to obtain missing data and inquire about possible repeat surgeries at other institutions. RESULTS We identified 407 patients who received CSDH evacuation via burr hole craniotomy. In total, 123 patients were treated with statins as part of their daily medication. Repeat surgery was performed in 26 patients in the statin group (21.1%) and 57 patients in the non-statin group (20.1%, p = 0.81). Upon multivariate logistic regression analysis, neither of the variables statins, age, antithrombotic medication, Charlson comorbidity index, or Markwalder grading score yielded a statistically significant effect upon the revision rate. CONCLUSIONS We found no evidence for the protective effect of statins in patients who underwent surgery for CSDH. We thus conclude that statin therapy is not warranted for CSDH perioperatively.
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Affiliation(s)
- Johann Klein
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Lisa Mauck
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Gabriele Schackert
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thomas Pinzer
- Department of Neurosurgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Ebel F, Ullmann M, Guzman R, Soleman J. Does the discontinuation time of antiplatelet or anticoagulation treatment affect hemorrhagic complications in patients undergoing craniotomy for neurovascular lesions? Br J Neurosurg 2021; 35:619-624. [PMID: 34030525 DOI: 10.1080/02688697.2021.1929835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The number of patients treated with platelet inhibitors (PI) and/or anticoagulants (AC) in neurosurgery is increasing. The aim of this study was to analyse the effect of PI/AC discontinuation time on hemorrhagic events after craniotomy for neurovascular pathologies. METHODS The 30-day postoperative bleeding rates were retrospectively compared between short (≤5 days) and long (>5 days) discontinuation time of PI/AC before and after surgery. Kaplan-Meier survival analysis comparing time to postoperative bleeding and the effect of PI/AC discontinuation time on bleeding rates were analysed. Potential risk factors for postoperative bleeding were further analysed in uni- and multivariate analysis. RESULTS Out of 215 consecutive patients undergoing craniotomy for neurovascular lesions between January 2009 and April 2019, 23.3% were treated with PI/AC. Of these 36% (n = 18) and 20.8% (n = 10) were included in the short pre- and postoperative discontinuation group, respectively. Bleeding rates were comparable between the pre- and postoperative short and long discontinuation groups (preoperative 11.1% vs 10%, p = .659; postoperative 0% vs 13.2%, p = .566). In-hospital mortality rates and time to bleed of the groups were comparable as well. Similarly, the rate for thromboembolic events was not significantly affected by the pre- or postoperative discontinuation time of PI/AC. After multivariate analysis preoperative bleeding of the lesion was significantly associated with postoperative bleeding. CONCLUSIONS Patients with short discontinuation time of PI/AC treatment undergoing craniotomy for the treatment of neurovascular lesions do not appear to have increased rates of postoperative bleeding.
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Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Muriel Ullmann
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery - should the neurosurgeon really worry about it? Neurosurg Rev 2021; 44:2889-2898. [PMID: 33495921 PMCID: PMC8490225 DOI: 10.1007/s10143-021-01476-7] [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: 09/08/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 11/03/2022]
Abstract
There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (> = 7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (> = 7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR = 1.0516 [0.1187; 9.3132], p = 1.000; RR = 1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p = 0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery.
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Sastry RA, Pertsch N, Tang O, Shao B, Toms SA, Weil RJ. Frailty and Outcomes after Craniotomy or Craniectomy for Atraumatic Chronic Subdural Hematoma. World Neurosurg 2020; 145:e242-e251. [PMID: 33065346 DOI: 10.1016/j.wneu.2020.10.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Frailty is a measure of decreased physiologic reserve and has been associated with increased morbidity and mortality in a variety of surgical disciplines. No data exist regarding the relationship of frailty with adverse outcomes in craniotomy for chronic subdural evacuation. We assessed the relationship between frailty and the incidence of major postoperative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after craniotomy for atraumatic subdural evacuation. METHODS A retrospective cohort study was conducted on a population of 1647 adult patients undergoing craniotomy for evacuation of atraumatic subdural hematoma in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index (mFI-5). Multivariable logistic regression was performed using all covariates deemed eligible through clinical relevance and statistical significance. RESULTS The overall rates of major complication (25.4%), discharge to destination other than home (49.8%), 30-day readmission (11.7%), and 30-day mortality (12.8%) in this analysis were high and rose with increasing frailty. In multivariable regression analyses, medium frailty (mFI-5 = 2) was associated with increased odds of major complication (adjusted odds ratio [aOR] 1.64, 95% confidence interval [CI] 1.03-2.63), discharge to destination other than home (aOR 2.04, 95% CI 1.38-3.02), and 30-day mortality (aOR 2.27, 95% CI 1.08-4.78). High frailty (mFI-5 >2) was associated with increased odds of 30-day mortality (aOR 2.85, 95% CI 1.13-7.14). CONCLUSIONS Preoperative frailty, as determined by mFI-5, is associated with increased odds of major postoperative complication, discharge to destination other than home, and 30-day mortality after craniotomy for chronic subdural hematoma.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
| | - Nathan Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Oliver Tang
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Belinda Shao
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
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Mongardi L, Dones F, Mantovani G, De Bonis P, Rustemi O, Ricciardi L, Cavallo MA, Scerrati A. Low-Dose Acetylsalicylic Acid in Chronic Subdural Hematomas: A Neurosurgeon's Sword of Damocles. Front Neurol 2020; 11:550084. [PMID: 33133003 PMCID: PMC7550681 DOI: 10.3389/fneur.2020.550084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 08/21/2020] [Indexed: 01/17/2023] Open
Abstract
Background: The possible influence of different antithrombotic drugs on outcome after neurosurgical treatment of chronic subdural hematoma (CSDH) is still unclear. Nowadays, no randomized clinical trials are available. A metanalysis including 24 studies for a total of 1,812 pooled patients concluded that antiplatelets and anticoagulations present higher risk of recurrences. On the other hand, several studies highlighted that antithrombotic suspension, timing of surgery, and resumption of these drugs are still debated, and patients taking these present higher risk of thromboembolic events with no excess risk of bleed recurrences or worse functional outcome. Our assumption is that the real hemorrhagic risk related to antithrombotic drug continuation in CSDH may be overrated and the thromboembolic risk for discontinuation underestimated, especially in patients with high cardiovascular risk. Methods: A comprehensive literature review with the search terms “acetylsalicylic acid” and “chronic subdural x” was performed. Clinical status, treatment, time of drug discontinuation, complications (in particular, rebleeding or thromboembolic events), and clinical and radiological outcome at follow-up were evaluated. Results: Five retrospective studies were selected for the review, three of them reporting specifically low-dose acetylsalicylic intake and two of them general antithrombotic drugs for a total of 1,226 patients. Only two papers reported the thromboembolic rate after surgery; in one paper, it is not even divided from other cardiac complications. Conclusion: The literature review does not clarify the best management of low-dose acetylsalicylic in CSDH patients, in particular, concerning the balance between thromboembolic event rates and rebleeding risks. We do believe that CSDH precipitates the worsening of comorbidities with a resulting increased mortality. Further studies clearly evaluating the thromboembolic events are strongly needed to clarify this topic. In this perspective paper, we discuss the difficult choice of low-dose acetylsalicylic acid (LDAA) management in patients suffering from chronic subdural hematoma (CSDH). The balance between hemorrhagic and thromboembolic risks often represents a sword of Damocles for neurosurgeons, especially when dealing with patients with high cardiovascular risk. No guidelines are currently available, and a survey by Kamenova et al. showed that most neurosurgeons discontinue LDAA treatment for at least 7 days in the perioperative period of surgical evacuation of CSDH, even though recent studies show that early LDAA resumption might be safe. Thrombosis prophylaxis is administered by only 60%, even though patients with CSDH are at high risk of developing thromboembolic complications. We would like to bring attention to this controversial issue.
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Affiliation(s)
- Lorenzo Mongardi
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy
| | - Flavia Dones
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy
| | - Giorgio Mantovani
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy
| | - Pasquale De Bonis
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | | | - Luca Ricciardi
- Neurosurgery, Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Italy
| | - Michele Alessandro Cavallo
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Alba Scerrati
- Neurosurgery Department, University Hospital S. Anna, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Systematic review of current randomised control trials in chronic subdural haematoma and proposal for an international collaborative approach. Acta Neurochir (Wien) 2020; 162:763-776. [PMID: 32025806 DOI: 10.1007/s00701-020-04218-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is a pathology that is frequently encountered by neurosurgeons. Nevertheless, there is a lack of guidelines based on solid evidence. There has been a recent and considerable increase in the interest on management and outcomes for CSDH. Therefore, we systematically reviewed all currently running randomised controlled trials (RCTs) in chronic subdural haematoma to understand the areas under investigation and plan future collaborative trials. METHODS Clinical trials databases (Cochrane Controlled Register of Trials, WHO ICTRP and clinical trials.gov) were searched for trials relevant to chronic subdural haematoma. It was then established which trials were currently running and fulfilled robust research methodology for a RCT. RESULTS There are 26 currently running RCTs in CSDH, with the most common topics covering application of steroids (7), surgical techniques (5) and tranexamic acid (5). Further to this, there are trials running on other pharmacological agents (4), middle meningeal artery (MMA) embolisation (2) and peri-operative management (3). CONCLUSIONS Pharmacological agents are a particular focus of CSDH management currently, and a wealth of studies on steroids will hopefully lead to more harmonised, evidence-based practice regarding this in the near future. Surgical techniques and new procedures such as MMA embolisation are also important focuses for improving patient outcomes. There is an on-going need for future RCTs and evidence-based guidelines in CSDH, particularly including low- and middle-income countries, and it is hoped that the establishment of the iCORIC (International COllaborative Research Initiative on Chronic Subdural Haematoma) will help address this.
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9
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Tommiska P, Lönnrot K, Raj R, Luostarinen T, Kivisaari R. Transition of a Clinical Practice to Use of Subdural Drains after Burr Hole Evacuation of Chronic Subdural Hematoma: The Helsinki Experience. World Neurosurg 2019; 129:e614-e626. [DOI: 10.1016/j.wneu.2019.05.230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
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10
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Soleman J, Lutz K, Schaedelin S, Kamenova M, Guzman R, Mariani L, Fandino J. In Reply: Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial). Neurosurgery 2019; 85:E797-E798. [DOI: 10.1093/neuros/nyz291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jehuda Soleman
- Department of Neurosurgery University Hospital of Basel Basel, Switzerland
- Faculty of Medicin University of Basel Basel, Switzerland
| | - Katharina Lutz
- Department of Neurosurgery University Hospital of Basel Basel, Switzerland
| | | | - Maria Kamenova
- Department of Neurosurgery University Hospital of Basel Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery University Hospital of Basel Basel, Switzerland
- Faculty of Medicin University of Basel Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery University Hospital of Basel Basel, Switzerland
- Faculty of Medicin University of Basel Basel, Switzerland
| | - Javier Fandino
- Department of Neurosurgery Kantonsspital Aarau Aarau, Switzerland
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11
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Poon MTC, Rea C, Kolias AG, Brennan PM. Influence of Antiplatelet and Anticoagulant Drug Use on Outcomes after Chronic Subdural Hematoma Drainage. J Neurotrauma 2019; 38:1177-1184. [PMID: 30526281 PMCID: PMC8060161 DOI: 10.1089/neu.2018.6080] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We aim to describe the outcomes after chronic subdural hematoma drainage (CSDH) management in a large cohort of patients on antithrombotic drugs, either antiplatelets or anticoagulants, at presentation and to inform clinical decision making on the timing of surgery and recommencement of these drugs. We used data from a previous UK-based multi-center, prospective cohort study. Outcomes included recurrence within 60 days, functional outcome at discharge, and thromboembolic event during hospital stay. We performed Cox regression on recurrence and multiple logistic regression on functional outcome. There were 817 patients included in the analysis, of which 353 (43.2%) were on an antithrombotic drug at presentation. We observed a gradual reduction in risk of recurrence for patients during the 6 weeks post-CSDH surgery. Neither antiplatelet nor anticoagulant drug use influenced risk of CSDH recurrence (hazard ratio, 0.93; 95% confidence interval [CI], 0.58–1.48; p = 0.76) or persistent/worse functional impairment (odds ratio, 1.08; 95% CI, 0.76–1.55; p = 0.66). Delaying surgery after cessation of antiplatelet drug did not affect risk of bleed recurrence. There were 15 in-hospital thromboembolic events recorded. Events were more common in the group pre-treated with antithrombotic drugs (3.3%) compared to the non-antithrombotic group (0.9%). Patients on an antithrombotic drug pre-operatively were at higher risk of thromboembolic events with no excess risk of bleed recurrence or worse functional outcome after CSDH drainage. The data did not support delaying surgery in patients on antithrombotic therapy. In the absence of a randomized controlled trial, early surgery and early antithrombotic recommencement should be considered in those at high risk of thromboembolic events.
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Affiliation(s)
- Michael T C Poon
- Department of Clinical Neuroscience, Western General Hospital, Edinburgh, United Kingdom.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
| | - Catherine Rea
- Department of Haematology, Eastbourne District General Hospital, Eastbourne, United Kingdom
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom.,Surgery Theme, Cambridge Clinical Trials Unit, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Paul M Brennan
- Department of Clinical Neuroscience, Western General Hospital, Edinburgh, United Kingdom.,Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
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12
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Kamenova M, Mueller C, Coslovsky M, Guzman R, Mariani L, Soleman J. Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study. Trials 2019; 20:70. [PMID: 30665464 PMCID: PMC6341728 DOI: 10.1186/s13063-018-3064-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low-dose acetylsalicylic acid (ASA) in patients with chronic subdural hematoma (cSDH) represents a significant neurosurgical challenge. While continuation of ASA during the perioperative phase might increase recurrence and bleeding rates, discontinuation increases the risk of thromboembolic events. The aim of this study is to compare the postoperative recurrence and cardiovascular complication rates of patients undergoing burr-hole trepanation for cSDH with and without discontinuation of ASA. METHODS In this prospective randomized, placebo-controlled, double-blinded study we include all patients undergoing burr-hole drainage of cSDH who are under ASA treatment. The patients are randomized into two groups, one receiving ASA and the other placebo perioperatively. The study primarily seeks to compare the rate of recurrent events under ASA to that under placebo treatment. Secondary objectives are thromboembolic event rate, perioperative blood loss, postoperative anemia, intra- and postoperative blood transfusion rate, and clinical outcome. DISCUSSION To date, there is no evidence-based consensus on how to manage patients undergoing burr-hole drainage for cSDH who are under ASA treatment. Therefore, the decision to maintain or interrupt ASA treatment is based mostly on the surgeons' preference. A randomized placebo-controlled study for this frequent question is urgently needed in order to provide class I evidence for the best possible treatment of this large group of patients. TRIAL REGISTRATION ClinicalTrials.gov: NCT03120182 . Initial Release: 19.04.2017. STUDY PROTOCOL V2_23.02.2017.
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Affiliation(s)
- Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland.
| | - Christian Mueller
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 CH, Basel, Switzerland
| | - Michael Coslovsky
- Clinical Trial Unit University Hospital of Basel, Spitalstrasse 12, 4031 CH, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
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Baschera D, Tosic L, Westermann L, Oberle J, Alfieri A. Treatment Standards for Chronic Subdural Hematoma: Results from a Survey in Austrian, German, and Swiss Neurosurgical Units. World Neurosurg 2018; 116:e983-e995. [DOI: 10.1016/j.wneu.2018.05.145] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/19/2018] [Accepted: 05/19/2018] [Indexed: 10/16/2022]
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