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

Andexanet alfa therapy showed No increased rate of thromboembolic events in spontaneous intracranial hemorrhage patients: A multicenter electronic health record study

•Intracranial hemorrhage accounts for two out of every three major intracranial hemorrhages.•Systemic anticoagulation is routinely prescribed for prevention of cerebrovascular accidents.•The FDA approved Andexanet alfa to treat life-threatening bleeding.•Andexanet alfa relationship to outcomes requires further investigation.

Venous thromboembolism and intracranial hemorrhage in patients undergoing glioblastoma surgery

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.

Incidence and Risk Factors of Lower-Extremity Deep Vein Thrombosis After Thrombolysis Among Patients with Acute Ischemic Stroke

Background

Deep vein thrombosis (DVT) is common among patients with stroke. However, the incidence of DVT in acute ischemic stroke patients treated with thrombolytic therapy and the risk factors associated with this condition are unknown.

Objective

This study aimed to investigate the incidence and risk factors of DVT after thrombolysis in patients with acute ischemic stroke.

Settings and Methods

We retrospectively reviewed the medical records of all patients with acute ischemic stroke who underwent ultrasonic examination after intravenous thrombolysis between April 2017 and December 2019 at the stroke center of the First Hospital of Jilin University, China. Color duplex ultrasound was used to diagnosis DVT in all patients within 72 h after intravenous thrombolysis. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for DVT.

Results

Overall, 474 patients were included in the study. Of these, 75 (15.8%) developed DVT (95% confidence interval 12.5–19.1). Older age was the risk factor that most significantly affected the development of DVT (p = 0.001). Compared to patients younger than 60 years old, those aged 60–69 years and ≥70 years had a higher risk of DVT, at rates of 2.201 (95% CI: 1.033–4.689; p < 0.05) and 4.241 (95% CI: 2.016–8.922; p < 0.001) times higher, respectively. Patients with higher triglyceride levels (odds ratio 0.545, 95% CI: 0.372–0.799, p = 0.002) and longer activated partial thromboplastin time (OR 0.927, 95% CI: 0.862–0.996, p = 0.040) were less likely to have DVT.

Conclusion

DVT is a common complication among patients undergoing intravenous thrombolysis after acute ischemic stroke. Advanced age may increase the occurrence of DVT to some extent. For these patients, safe antiplatelet therapy should be explored and implemented as soon as possible.

Development and validation of a novel risk assessment model to estimate the probability of pulmonary embolism in postoperative patients

Pulmonary embolism (PE) is a leading cause of mortality in postoperative patients. Numerous PE prevention clinical practice guidelines are available but not consistently implemented. This study aimed to develop and validate a novel risk assessment model to assess the risk of PE in postoperative patients. Patients who underwent Grade IV surgery between September 2012 and January 2020 (n = 26,536) at the Affiliated Dongyang Hospital of Wenzhou Medical University were enrolled in our study. PE was confirmed by an identified filling defect in the pulmonary artery system in CT pulmonary angiography. The PE incidence was evaluated before discharge. All preoperative data containing clinical and laboratory variables were extracted for each participant. A novel risk assessment model (RAM) for PE was developed with multivariate regression analysis. The discrimination ability of the RAM was evaluated by the area under the receiver operating characteristic curve, and model calibration was assessed by the Hosmer–Lemeshow statistic. We included 53 clinical and laboratory variables in this study. Among them, 296 postoperative patients developed PE before discharge, and the incidence rate was 1.04%. The distribution of variables between the training group and the validation group was balanced. After using multivariate stepwise regression, only variable age (OR 1.070 [1.054–1.087], P < 0.001), drinking (OR 0.477 [0.304–0.749], P = 0.001), malignant tumor (OR 2.552 [1.745–3.731], P < 0.001), anticoagulant (OR 3.719 [2.281–6.062], P < 0.001), lymphocyte percentage (OR 2.773 [2.342–3.285], P < 0.001), neutrophil percentage (OR 10.703 [8.337–13.739], P < 0.001), red blood cell (OR 1.872 [1.384–2.532], P < 0.001), total bilirubin (OR 1.038 [1.012–1.064], P < 0.001), direct bilirubin (OR 0.850 [0.779–0.928], P < 0.001), prothrombin time (OR 0.768 [0.636–0.926], P < 0.001) and fibrinogen (OR 0.772 [0.651–0.915], P < 0.001) were selected and significantly associated with PE. The final model included four variables: neutrophil percentage, age, malignant tumor and lymphocyte percentage. The AUC of the model was 0.949 (95% CI 0.932–0.966). The risk prediction model still showed good calibration, with reasonable agreement between the observed and predicted PE outcomes in the validation set (AUC 0.958). The information on sensitivity, specificity and predictive values according to cutoff points of the score in the training set suggested a threshold of 0.012 as the optimal cutoff value to define high-risk individuals. We developed a new approach to select hazard factors for PE in postoperative patients. This tool provided a consistent, accurate, and effective method for risk assessment. This finding may help decision-makers weigh the risk of PE and appropriately select PE prevention strategies.

[Incidence and risk factors of venous thromboembolic events after resection of various brain tumors]

Venous thromboembolic events (VTE) can significantly complicate postoperative period in neurosurgical patients. It is known that patients with brain tumors are especially susceptible to VTE.

OBJECTIVE

To determine the incidence and risk factors of VTE in patients with various brain tumors.

MATERIAL AND METHODS

All patients with brain tumors underwent surgery in 2019 (n=610). They were divided into the groups depending on tumor type: sellar region, intracerebral, extracerebral neoplasms and metastases. All patients underwent screening and prevention of VTE in accordance with the protocol accepted in the hospital. We analyzed the incidence of VTE in each group and significance of various risk factors.

RESULTS

Overall incidence of VTE was 14.9% (91 cases). Deep vein thrombosis (DVT) was the most common - 85 cases (93.4%). Less common events were DVT combined with pulmonary embolism (PE) (n=5, 5.5%) and PE alone (n=1; 1.1%). PE caused death in 2 cases (0.3%). In patients with sellar tumors, incidence was 21.7% [13.4%; 29.35%], among intracerebral tumors - 13.8% [9.04%; 18.62%], extracerebral neoplasms - 15.4% [11.02%; 19.69%], metastases - 7.9% [1.32%; 11.84%]. Univariate and multivariate analysis revealed some risk factors of VTEs such as gender, age, surgery time, length of ICU-stay over 12 hours, body mass index >30 kg/m². Moreover, risk factors have different significance in patients with different types of tumors.

CONCLUSION

In this study, we found a high incidence of VTE among patients with brain tumors. Incidence and risk factors of VTE depend on the type of tumor.

Impaired contraction of blood clots precedes and predicts postoperative venous thromboembolism

Deep vein thrombosis (DVT) is a common but unpredictable complication of surgical interventions. To reveal an association between the blood clot contraction (retraction) and the incidence of postoperative venous thrombosis, 78 patients with brain tumors that were operated on were studied, of which 23 (29%) were diagnosed with postoperative DVT. A clot contraction assay, along with other hemostatic and hematologic tests, was performed 1–3 days before the surgery and on the 1st day and 5–7th days after the surgery. On the 1st postoperative day, clot contraction was significantly suppressed in patients who subsequently developed DVT, compared to the patients without DVT. Importantly, this difference was observed at least 5 days before DVT had developed. The weakening of contraction on the 1st postoperative day was more pronounced in the DVT patients with malignant versus benign brain tumors, atherosclerosis, hypertension, as well as in patients receiving steroids before and during the operation. These results indicate that impaired clot contraction in the postoperative period is associated with imminent DVT, suggesting that it is a prothrombotic risk factor and promotional mechanism. The clot contraction assay has a predictive value in assessing the threat of postoperative thrombosis in patients with benign and malignant brain tumors.

Perioperative anticoagulation in patients with intracranial meningioma: No increased risk of intracranial hemorrhage?

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.