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Grottke O, Afshari A, Ahmed A, Arnaoutoglou E, Bolliger D, Fenger-Eriksen C, von Heymann C. Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding. Eur J Anaesthesiol 2024; 41:327-350. [PMID: 38567679 DOI: 10.1097/eja.0000000000001968] [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: 04/04/2024]
Abstract
BACKGROUND Anticoagulation is essential for the treatment and prevention of thromboembolic events. Current guidelines recommend direct oral anticoagulants (DOACs) over vitamin K antagonists in DOAC-eligible patients. The major complication of anticoagulation is serious or life-threatening haemorrhage, which may necessitate prompt haemostatic intervention. Reversal of DOACs may also be required for patients in need of urgent invasive procedures. This guideline from the European Society of Anaesthesiology and Intensive Care (ESAIC) aims to provide evidence-based recommendations and suggestions on how to manage patients on DOACs undergoing urgent or emergency procedures including the treatment of DOAC-induced bleeding. DESIGN A systematic literature search was performed, examining four drug comparators (dabigatran, rivaroxaban, apixaban, edoxaban) and clinical scenarios ranging from planned to emergency surgery with the outcomes of mortality, haematoma growth and thromboembolic complications. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to assess the methodological quality of the included studies. Consensus on the wording of the recommendations was achieved by a Delphi process. RESULTS So far, no results from prospective randomised trials comparing two active comparators (e.g. a direct reversal agent and an unspecific haemostatic agent such as prothrombin complex concentrate: PCC) have been published yet and the majority of publications were uncontrolled and observational studies. Thus, the certainty of evidence was assessed to be either low or very low (GRADE C). Thirty-five recommendations and clinical practice statements were developed. During the Delphi process, strong consensus (>90% agreement) was achieved in 97.1% of recommendations and consensus (75 to 90% agreement) in 2.9%. DISCUSSION DOAC-specific coagulation monitoring may help in patients at risk for elevated DOAC levels, whereas global coagulation tests are not recommended to exclude clinically relevant DOAC levels. In urgent clinical situations, haemostatic treatment using either the direct reversal or nonspecific haemostatic agents should be started without waiting for DOAC level monitoring. DOAC levels above 50 ng ml-1 may be considered clinically relevant necessitating haemostatic treatment before urgent or emergency procedures. Before cardiac surgery under activated factor Xa (FXa) inhibitors, the use of andexanet alfa is not recommended because of inhibition of unfractionated heparin, which is needed for extracorporeal circulation. In the situation of DOAC overdose without bleeding, no haemostatic intervention is suggested, instead measures to eliminate the DOACs should be taken. Due to the lack of published results from comparative prospective, randomised studies, the superiority of reversal treatment strategy vs. a nonspecific haemostatic treatment is unclear for most urgent and emergency procedures and bleeding. Due to the paucity of clinical data, no recommendations for the use of recombinant activated factor VII as a nonspecific haemostatic agent can be given. CONCLUSION In the clinical scenarios of DOAC intake before urgent procedures and DOAC-induced bleeding, practitioners should evaluate the risk of bleeding of the procedure and the severity of the DOAC-induced bleeding before initiating treatment. Optimal reversal strategy remains to be determined in future trials for most clinical settings.
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Affiliation(s)
- Oliver Grottke
- From the Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse, Aachen, Germany (OG), Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet; & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester (AA), Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (AA), Department of Anaesthesiology, Larissa University Hospital, Larissa, Greece (EA), Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse, Basel, Switzerland (DB), Department of Anaesthesiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard, Aarhus, Denmark (CF-E) and Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Landsberger Allee, Berlin, Germany (CvH)
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Kumar N, Palmisciano P, Dhawan S, Boakye M, Drazin D, Sharma M. Spontaneous Spinal Hematoma in Patients Using Antiplatelets and Anticoagulants: A Systematic Review. World Neurosurg 2024; 184:e185-e194. [PMID: 38278210 DOI: 10.1016/j.wneu.2024.01.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Spontaneous spinal hematoma (SSH) is a debilitating complication in patients taking either antiplatelet (AP) or anticoagulation (AC) medications. SSH is rare and, therefore, a systematic review is warranted to re-examine and outline trends, clinical characteristics, and outcomes associated with SSH formation. METHODS PubMed, EMBASE, Scopus, and Web-of-Science were searched. Studies reporting clinical data of patients with SSH using AC medications were included. In addition, clinical studies meeting our a priori inclusion criteria limited to SSH were further defined in quality through risk bias assessment. RESULTS We included 10 studies with 259 patients' pooled data post-screening 3083 abstracts. Within the cohort (n = 259), the prevalence of idiopathic, nontraumatic SSH with concomitant treatment with AC medications was greater 191 (73.75%) compared with AP treatment (27%). The lumbar spine was the most common site of hematoma (41.70%), followed by the cervical (22.01%) and thoracic (8.49%) spine. Most patients had surgical intervention (70.27%), and 29.73% had conservative management. The pooled data suggest that immediate diagnosis and intervention are the best prognostic factors in clinical outcomes. American Spinal Injury Association grading at initial symptom onset and post-treatment showed the greatest efficacy in symptomatic relief (87.64%) and return of motor and sensory symptoms (39.19%). CONCLUSIONS Our review suggested that AC medications were related to SSH in most patients (74%), followed by APs (27%) and combined ACs + APs (1.9%). We recommend prompt intervention, a high suspicion for patients with neurologic deficits and diagnostic imaging before intervention to determine a case-specific treatment plan.
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Affiliation(s)
- Nitesh Kumar
- Clinical Medicine, Windsor University School of Medicine, Chicago, Illinois, USA
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Doniel Drazin
- Department of Neurosurgery, Providence Everett Neuroscience Center, Everett, Washington, USA
| | - Mayur Sharma
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.
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Park MS, Moon SH, Jang SB, Kim JW, Sung PS. Spontaneous Hematomyelia Associated with the Use of Non-vitamin K Antagonist. J Neurol Surg A Cent Eur Neurosurg 2023; 84:212-215. [PMID: 34126639 DOI: 10.1055/s-0041-1728768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vitamin K antagonists have been frequently prescribed as anticoagulants with the potential side effect of spontaneous hematomyelia with a poor prognosis. However, to our knowledge, there has been no report of spontaneous hematomyelia combined with the use of a non-vitamin K antagonist. A 63-year-old man presented with left leg weakness, impaired sensation, and urinary retention while taking rivaroxaban (non-vitamin K antagonist) for 4 months for atrial fibrillation. Anticoagulant agents were discontinued. Methylprednisolone pulse therapy was administered without surgical hematoma evacuation. Three months after the initial development of the hematomyelia, the symptoms improved to grade 5 for both lower extremities, and there was complete recovery in sensory and urinary functions. This might be the first description of a complete recovery of neurologic deficits without hematoma evacuation in spontaneous hematomyelia patients caused by non-vitamin K antagonist therapy.
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Affiliation(s)
- Moon Soo Park
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Seong-Hwan Moon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Bo Jang
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Jeoung Woo Kim
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Medical College of Hallym University, Gyeonggi-do, Republic of Korea
| | - Paul S Sung
- Doctoral Program in Physical Therapy, The Herbert H. and Grace A. Dow College of Health Professions, Central Michigan University, Mount Pleasant, Michigan, United States
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Alhalabi OT, Heene S, Landré V, Neumann JO, Scherer M, Ishak B, Kiening K, Zweckberger K, Unterberg AW, Younsi A. Spinal oncologic paraparesis: Analysis of neurological and surgical outcomes in patients with intramedullary, extramedullary, and extradural tumors. Front Oncol 2023; 12:1003084. [PMID: 36686806 PMCID: PMC9846080 DOI: 10.3389/fonc.2022.1003084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/12/2022] [Indexed: 01/05/2023] Open
Abstract
Objectives Paraparesis due to oncologic lesions of the spine warrants swift neurosurgical intervention to prevent permanent disability and hence maintain independence of affected patients. Clinical parameters that predict a favorable outcome after surgical intervention could aid decision-making in emergency situations. Methods Patients who underwent surgical intervention for paraparesis (grade of muscle strength <5 according to the British Medical Research Council grading system) secondary to spinal neoplasms between 2006 and 2020 were included in a single-center retrospective analysis. Pre- and postoperative clinical data were collected. The neurological status was assessed using the modified McCormick Disability Scale (mMcC) Score. In a univariate analysis, patients with favorable (discharge mMcC improved or stable at <3) and non-favorable outcome (discharge mMcC deteriorated or stable at >2) and different tumor anatomical compartments were statistically compared. Results 117 patients with oncologic paraparesis pertaining to intramedullary lesions (n=17, 15%), intradural extramedullary (n=24, 21%) and extradural lesions (n=76, 65%) with a mean age of 65.3 ± 14.6 years were included in the analysis. Thoracic tumors were the most common (77%), followed by lumbar and cervical tumors (13% and 12%, respectively). Surgery was performed within a mean of 36±60 hours of admission across all tumors and included decompression over a median of 2 segments (IQR:1-3) and mostly subtotal tumor resection (n=83, 71%). Surgical and medical complications were documented in 9% (n=11) and 7% (n=8) of cases, respectively. The median hospital length-of-stay was 9 (7-13) days. Upon discharge, the median mMcC score had improved from 3 to 2 (p<0.0001). At last follow-up (median 180; IQR 51-1080 days), patients showed an improvement in their mean Karnofsky Performance Score (KPS) from 51.7±18.8% to 65.3±20.4% (p<0.001). Localization in the intramedullary compartment, a high preoperative mMcC score, in addition to bladder and bowel dysfunction were associated with a non-favorable outcome (p<0.001). Conclusion The data presented on patients with spinal oncologic paraparesis provide a risk-benefit narrative that favors surgical intervention across all etiologies. At the same time, they outline clinical factors that confer a less-favorable outcome like intramedullary tumor localization, a high McCormick score and/or bladder and bowel abnormalities at admission.
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Affiliation(s)
- Obada T. Alhalabi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany,*Correspondence: Obada T. Alhalabi,
| | - Stefan Heene
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Vincent Landré
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, City Hospital of Brunswick, Brunswick, Germany
| | | | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Farzanegan G, Ahmadpour F, Khoshmohabbat H, Khadivi M, Rasouli HR, Eslamian M. The Effect of Topical Tranexamic Acid on Intraoperative Blood Loss in Patients Undergoing Posterior Lumbar Laminectomy and Discectomy: A Randomized, Double-Blind, Controlled Trial Study. Asian Spine J 2022; 16:857-864. [PMID: 35184518 PMCID: PMC9827208 DOI: 10.31616/asj.2021.0285] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/09/2021] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Randomized, double-blind, controlled trial study. PURPOSE This study aimed to evaluate the safety and efficacy of topical tranexamic acid (TXA) on intraoperative blood loss (IBL) in patients that have degenerative lumbar canal stenosis and undergo posterior lumbar laminectomy and discectomy. OVERVIEW OF LITERATURE The volume of IBL is directly proportional to potential surgical complications. Recent reports have shown that the topical use of antifibrinolytic drugs, such as TXA, during surgery might decrease IBL and improve patient outcomes. METHODS A total of 104 patients with lumbar canal stenosis were enrolled in this randomized, double blinded clinical trial. Participants were randomized and divided into two groups: TXA (54 cases) and control (50 cases). In the TXA group, a TXA solution was used for washing and soaking, whereas, in the control group, irrigation of wound was with normal saline. IBL, pre- and postoperative coagulative studies, operation time, conventional hemostatic agent usage, systemic complications, and length of hospitalization were consecutively recorded. All participants were followed for an additional two months to gather data on their recovery status and time to return to work (RTW). RESULTS At baseline, there was no difference in clinical or lab findings, between the groups. IBL and use of hemostatic agents were significantly decreased in TXA group, as compared to the control group (p=0.001 and p=0.011, respectively). Systemic complications, length of hospitalization, and RTW were not significantly different between groups (p=0.47, p=0.38, and p=0.08, respectively). CONCLUSIONS This study showed that topical use of TXA during surgery may decrease IBL and minimize the use of hemostatic materials during posterior midline-approach laminectomy and discectomy, without increasing the potential for complications seen with intravenous TXA usage.
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Affiliation(s)
| | - Fathollah Ahmadpour
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Hadi Khoshmohabbat
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Masoud Khadivi
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran,
Iran
| | - Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Mohammad Eslamian
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran,
Iran
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Andrea I, Federica N, Adolfo DL, Maurizio S. Holocordic Spinal Subdural Hematoma: A Challenging Management In Emergency. Literature Review. World Neurosurg 2022; 160:44-49. [PMID: 35066207 DOI: 10.1016/j.wneu.2022.01.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/12/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Iaquinandi Andrea
- Department of Neurosurgery, Policlinico "Tor Vergata", University of Rome ''Tor Vergata''. Viale Oxford 81, 00133 Rome, Italy.
| | - Novegno Federica
- Department of Neurosurgery, Policlinico "Tor Vergata", University of Rome ''Tor Vergata''. Viale Oxford 81, 00133 Rome, Italy
| | - De Luna Adolfo
- Department of Neurosurgery, Policlinico "Tor Vergata", University of Rome ''Tor Vergata''. Viale Oxford 81, 00133 Rome, Italy
| | - Salvati Maurizio
- Department of Neurosurgery, Policlinico "Tor Vergata", University of Rome ''Tor Vergata''. Viale Oxford 81, 00133 Rome, Italy
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Mishra AK, Sahu KK, John K, Lal A. Fixed-Dose 4-Factor Prothrombin Complex Concentrate Administration: In Search of the Optimal Dosing. J Emerg Med 2021; 59:313-314. [PMID: 32948285 DOI: 10.1016/j.jemermed.2019.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 12/09/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Ajay Kumar Mishra
- Postgraduates in Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Kamal Kant Sahu
- Postgraduates in Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Kevin John
- Believers Church Medical College, Tiruvalla, India
| | - Amos Lal
- Department of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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Faulkner H, Chakankar S, Mammi M, Lo JYT, Doucette J, Al-Otaibi N, Abboud J, Le A, Mekary RA, Bunevicius A. Safety and efficacy of prothrombin complex concentrate (PCC) for anticoagulation reversal in patients undergoing urgent neurosurgical procedures: a systematic review and metaanalysis. Neurosurg Rev 2020; 44:1921-1931. [PMID: 33009989 DOI: 10.1007/s10143-020-01406-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 09/28/2020] [Indexed: 12/31/2022]
Abstract
Anticoagulant therapy poses a significant risk for patients undergoing emergency neurosurgery procedures, necessitating reversal with prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). Data on PCC efficacy lack consistency in this setting. This systematic review and metaanalysis aimed to evaluate efficacy and safety of PCC for anticoagulation reversal in the context of urgent neurosurgery. Articles from PubMed, Embase, and Cochrane databases were screened according to the PRISMA checklist. Adult patients receiving anticoagulation reversal with PCC for emergency neurosurgical procedures were included. When available, patients who received FFP were included as a comparison group. Pooled estimates of observational studies were calculated for efficacy and safety outcomes via random-effects modeling. Initial search returned 4505 articles, of which 15 studies met the inclusion criteria. Anticoagulants used included warfarin (83%), rivaroxaban (6.8%), phenprocoumon (6.1%), apixaban (2.2%), and dabigatran (1.5%). The mean International Normalized Ratio (INR) prePCC administration ranged from 2.3 to 11.7, while postPCC administration from 1.1 to 1.4. All-cause mortality at 30 days was 27% (95%CI 21, 34%; I2 = 44.6%; p-heterogeneity = 0.03) and incidence of thromboembolic events was 6.00% among patients treated with PCC (95%CI 4.00, 10.0%; I2 = 0%; p-heterogeneity = 0.83). Results comparing PCC and FFP demonstrated no statistically significant differences in INR reversal, mortality, or incidence of thromboembolic events. This metaanalysis demonstrated adequate safety and efficacy for PCC in the reversal of anticoagulation for urgent neurosurgical procedures. There was no significant difference between PCC and FFP, though further trials would be useful in demonstrating the safety and efficacy of PCC in this setting.
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Affiliation(s)
| | | | - Marco Mammi
- Neurosurgery Unit, Department of Neurosciences, University of Turin, via Cherasco 15, 10126, Turin, Italy
| | - Jack Yu Tung Lo
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Department of Neurosurgery, National Neuroscience Institute, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore
| | - Joanne Doucette
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Nawaf Al-Otaibi
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Judi Abboud
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Andrew Le
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA
| | - Rania A Mekary
- School of Pharmacy, MCPHS University, Boston, MA, 02115, USA. .,Neurosurgery Unit, Department of Neurosciences, University of Turin, via Cherasco 15, 10126, Turin, Italy.
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A review of anticoagulation in patients with central nervous system malignancy: between a rock and a hard place. J Neurol 2020; 268:2390-2401. [PMID: 32124043 DOI: 10.1007/s00415-020-09775-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
The incidence and prevalence of patients who develop primary and secondary metastatic central nervous system cancer (CNS) is increasing. This is a consequence of advancements in the sensitivity and availability of diagnostic imaging, and improved therapeutic options, leading to increased detection of CNS malignancies and improved survival. These patients are at very high risk of thrombosis as well as haemorrhage, and the optimum management of anticoagulation can be challenging for treating clinicians, particularly as robust prospective evidence is sparse. In this focused review, we discuss (1) risk factors for thrombosis and bleeding in these patients, (2) management of acute venous thromboembolism (VTE) including evidence for direct oral anticoagulants, and how to approach patients with contraindications to anticoagulation, (3) ambulatory VTE prophylaxis, (4) VTE prophylaxis in patients who have undergone craniotomy for cancer, and (5) management of anticoagulation-related intracranial haemorrhage. Based on review of the available literature and author opinion, we propose practical management algorithms to aid clinicians faced with treating CNS cancer patients with thrombosis or CNS haemorrhage.
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Beynon C, Olivares A, Gumbinger C, Younsi A, Zweckberger K, Unterberg AW. In Reply to the Letter to the Editor Regarding "Management of Spinal Emergencies in Patients on Direct Oral Anticoagulants". World Neurosurg 2019; 132:447-448. [PMID: 31810151 DOI: 10.1016/j.wneu.2019.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Christopher Beynon
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Arturo Olivares
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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Mishra AK, Sahu KK, Basaula NP, Lal A. Letter to the Editor Regarding "Management of spinal emergencies in patients on direct oral anticoagulants". World Neurosurg 2019; 132:446. [PMID: 31810150 DOI: 10.1016/j.wneu.2019.08.107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 08/15/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Ajay Kumar Mishra
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Nirmal Prasad Basaula
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Amos Lal
- Department of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
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