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Brown NJ, Hartke JN, Pacult M, Burkett KR, Gendreau J, Catapano JS, Lawton MT. Tranexamic Acid Demonstrates Efficacy without Increased Risk for Venous Thromboembolic Events in Cranial Neurosurgery: Systematic Review of the Evidence and Current Applications in Nontraumatic Pathologies. World Neurosurg 2024; 183:29-40. [PMID: 38052364 DOI: 10.1016/j.wneu.2023.11.148] [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: 09/19/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND The cautionary stance normally taken towards tranexamic acid (TXA) is rooted in concerns regarding its complication profile, namely its purported risk for venous thromboembolic events (VTEs). In the present review, we intend to bring increased attention to TXA as a remarkably valuable tool that does not appear to increase the risk for VTE when used as indicated in select patients. METHODS We queried three databases to identify reporting use of TXA during nontraumatic cranial neurosurgery procedures (excluded traumatic brain injury). Data gathered included VTE complications, deep venous thrombosis, use of allogeneic blood transfusions, estimated blood loss, and operative duration. RESULTS Twenty-eight studies were deemed eligible for inclusion in the present meta-analysis, including nine studies on surgical resection of intracranial neoplasms, ten studies on aneurysmal subarachnoid hemorrhage, and nine studies on craniosynostosis. In brain tumor surgery, TXA appears to successfully reduce blood loss without predisposing patients to VTE or seizure (P < 0.01). However, it does not appear to reduce rates of vasospasm in aneurysmal subarachnoid hemorrhage (P = 0.27), and its administration is not associated with clinically meaningful differences in long term neurological outcomes. For pediatric patients undergoing craniosynostosis procedures, TXA similarly reduces blood loss (P < 0.01). Nonetheless, low dosing protocols should be used because they appear effective and the effects of high dose TXA in children have not been studied. CONCLUSIONS TXA is an effective hemostatic agent that can be administered to reduce blood loss and transfusion requirements for a wide range of neurosurgical applications in a broad spectrum of patient populations.
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Affiliation(s)
- Nolan J Brown
- Department of Neurological Surgery, University of California-Irvine, Orange, California, USA
| | - Joelle N Hartke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark Pacult
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kyle R Burkett
- Department of Neurological Surgery, University of California-Irvine, Orange, California, USA
| | - Julian Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Li S, Liu M, Yang J, Yan X, Wu Y, Zhang L, Zeng M, Zhou D, Peng Y, Sessler DI. Intravenous tranexamic acid for intracerebral meningioma resections: A randomized, parallel-group, non-inferiority trial. J Clin Anesth 2024; 92:111285. [PMID: 37857168 DOI: 10.1016/j.jclinane.2023.111285] [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: 05/22/2023] [Revised: 09/14/2023] [Accepted: 10/08/2023] [Indexed: 10/21/2023]
Abstract
STUDY OBJECTIVES Tranexamic acid (TXA) is an antifibrinolytic that is widely used to reduce surgical bleeding. However, TXA occasionally causes seizures and the risk might be especially great after neurosurgery. We therefore tested the hypothesis that TXA does not meaningfully increase the risk of postoperative seizures within 7 days after intracranial tumor resections. DESIGN Randomized, double-blind, placebo-controlled, non-inferiority trial. SETTING Beijing Tiantan Hospital, Capital Medical University. PATIENTS 600 patients undergoing supratentorial meningioma resection were included from October 2020 to August 2022. INTERVENTIONS Patients were randomly assigned to a single dose of 20 mg/kg of TXA after induction (n = 300) or to the same volume of normal saline (n = 300). MEASUREMENT The primary outcome was postoperative seizures occurring within 7 days after surgery, analyzed in both the intention-to-treat and per-protocol populations. Non-inferiority was defined by an upper limit of the 95% confidence interval for the absolute difference being <5.5%. Secondary outcomes included incidence of non-epileptic complication within 7 days, changes in hemoglobin concentration, estimated intraoperative blood loss. Post hoc analyses included the types and timing of seizures, oozing assessment, and a sensitivity analysis for the primary outcome in patients with pathologic diagnosis of meningioma. MAIN RESULTS All 600 enrolled patients adhered to the protocol and completed the follow-up for the primary outcome. Postoperative seizures occurred in 11 of 300 (3.7%) of patients randomized to normal saline and 13 of 300 (4.3%) patients assigned to tranexamic acid (mean risk difference, 0.7%; 1-sided 97.5% CI, -∞ to 4.3%; P = 0.001 for noninferiority). No significant differences were observed in any secondary outcome. Post hoc analysis indicated similar amounts of oozing, calculated blood loss, recurrent seizures, and timing of seizures. CONCLUSION Among patients having supratentorial meningioma resection, a single intraoperative dose of TXA did not significantly reduce bleeding and was non-inferior with respect to postoperative seizures after surgery. REGISTRY INFORMATION This trial was registered at clinicaltrials.gov (NCT04595786) on October 22, 2020, by Dr.Yuming Peng.
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Affiliation(s)
- Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Jingchao Yang
- Department of Anesthesiology, Cancer Hospital, Chinses Academy of Medical Sciences, Beijing, PR China
| | - Xiang Yan
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
| | - Yaru Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Dabiao Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China.
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China; Outcome Research Consortium, Cleveland, OH, USA.
| | - Daniel I Sessler
- Outcome Research Consortium, Cleveland, OH, USA; Department of Outcome Research, Cleveland Clinic, Cleveland, OH, USA.
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Wang C, Li P. Risk factors for intraoperative blood loss in resection of intracranial meningioma: Analysis of 530 cases. PLoS One 2023; 18:e0291171. [PMID: 37682850 PMCID: PMC10490957 DOI: 10.1371/journal.pone.0291171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE Excision of intracranial meningioma has been associated with major intraoperative blood loss (IBL). The objective of the study was to identify factors affecting IBL during removal of meningioma. METHODS We retrospectively studied medical records of 530 adult patients who underwent surgery for intracranial meningioma at Sichuan Provincial People's Hospital between September 2018 and May 2022. We obtained the following data from each patient's medical chart: age, sex, height, weight, comorbidities, blood pressure, history of smoking and alcohol, imaging examination findings, pathologic diagnosis, albumin, creatinine, calcium, magnesium, hemoglobin (Hb), hematocrit, platelet count, activated partial thromboplastin time, international normalized ratio, fibrinogen concentration and blood transfusion. Univariate and multivariate analyses were performed to identify risk factors for greater IBL during removal of intracranial meningioma. RESULTS A total of 530 patients were included in our study. Univariate analysis revealed that sex (p = 0.004), two-dimensional (2D) tumor area (p < 0.001), sinus involvement (p = 0.014), World Health Organization grade (p = 0.015), preoperative albumin level (p = 0.032), preoperative Hb level (p = 0.001) and preoperative platelet count (p = 0.004) were significantly associated with greater IBL. Multivariate analysis revealed that greater 2D tumor area (p < 0.001), higher preoperative albumin concentration (p = 0.029) and higher preoperative platelet count (p = 0.03) were independent risk factors for greater IBL in resection of intracranial meningioma. CONCLUSION Larger tumor size, higher preoperative albumin concentration and higher preoperative platelet count were identified as independent risk factors for greater IBL in resection of intracranial meningioma.
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Affiliation(s)
- Chenghong Wang
- Department of Anesthesiology, Sichuan Provincial People’ Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Peng Li
- Department of Anesthesiology, Sichuan Provincial People’ Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
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Ghare A, Wong QHW, Sefcikova V, Waraich M, Samandouras G. Handling Severe Intraoperative Hemorrhage and Avoiding Iatrogenic Stroke During Brain Tumor Surgery: Techniques for Prevention of Hemorrhagic and Ischemic Complications. World Neurosurg 2023; 176:e135-e150. [PMID: 37178915 DOI: 10.1016/j.wneu.2023.05.019] [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: 01/03/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Nationwide databases show that iatrogenic stroke and postoperative hematoma are among the commonest complications in brain tumor surgery, with a 10-year incidence of 16.3/1000 and 10.3/1000, respectively. However, techniques for handling severe intraoperative hemorrhage and dissecting, preserving, or selectively obliterating vessels traversing the tumor are sparse in the literature. METHODS Records of the senior author's intraoperative techniques during severe haemorrhage and vessel preservation were reviewed and analyzed. Intraoperative media demonstrations of key techniques were collected and edited. In parallel, a literature search investigating technique description in handling severe intraoperative hemorrhage and vessel preservation in tumor surgery was undertaken. Histologic, anesthetic, and pharmacologic prerequisites of significant hemorrhagic complications and hemostasis were analyzed. RESULTS The senior author's techniques for arterial and venous skeletonization, temporary clipping with cognitive or motor mapping, and ION monitoring were categorized. Vessels interfacing with tumor are labeled intraoperatively as supplying/draining the tumor, or traversing en passant, while supplying/draining functional neural tissue. Intraoperative techniques of differentiation were analyzed and illustrated. Literature search found 2 vascular-related complication domains in tumor surgery: perioperative management of excessively vascular intraparenchymal tumors and lack of intraoperative techniques and decision processes for dissecting and preserving vessels interfacing or traversing tumors. CONCLUSIONS Literature searches showed a dearth of complication-avoidance techniques in tumor-related iatrogenic stroke, despite its high prevalence. A detailed preoperative and intraoperative decision process was provided along with a series of case illustrations and intraoperative videos showing the techniques required to reduce intraoperative stroke and associated morbidity addressing a void in complication avoidance of tumor surgery.
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Affiliation(s)
- Aisha Ghare
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Queenie Hoi-Wing Wong
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Viktoria Sefcikova
- UCL Queen Square Institute of Neurology, University College London, London, United Kingdom; The University of Queensland Medical School, Brisbane, Queensland, Australia
| | - Manni Waraich
- Department of Neuroanaesthesia, The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - George Samandouras
- Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, United Kingdom; UCL Queen Square Institute of Neurology, University College London, London, United Kingdom.
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Clynch AL, Gillespie CS, Richardson GE, Mustafa MA, Islim AI, Keshwara SM, Bakhsh A, Kumar S, Zakaria R, Millward CP, Mills SJ, Brodbelt AR, Jenkinson MD. Tranexamic acid use in meningioma surgery - A systematic review and meta-analysis. J Clin Neurosci 2023; 110:53-60. [PMID: 36796271 DOI: 10.1016/j.jocn.2023.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 01/02/2023] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
Tranexamic Acid (TXA) has been used in medical and surgical practice to reduce haemorrhage. The aim of this review was to evaluate the effect of TXA use on intraoperative and postoperative outcomes of meningioma surgery. A systematic review and meta-analysis was conducted in accordance with the PRISMA statement and registered in PROSPERO (CRD42021292157). Six databases were searched up to November 2021 for phase 2-4 control trials or cohort studies, in the English language, examining TXA use during meningioma surgery. Studies ran outside of dedicated neurosurgical departments or centres were excluded. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Random effects meta-analysis were performed to delineate differences in operative and postoperative outcomes. Four studies (281 patients) were included. TXA use significantly reduced intraoperative blood loss (mean difference 315.7 mls [95% confidence interval [CI] -532.8, -98.5]). Factors not affected by TXA use were transfusion requirement (odds ratio = 0.52; 95% CI 0.27, 0.98), operation time (mean difference = -0.2 h; 95% CI -0.8, 0.4), postoperative seizures (Odds Ratio [OR] = 0.88; 95% CI 0.31, 2.53), hospital stay (mean difference = -1.2; 95% CI -3.4, 0.9) and disability after surgery (OR = 0.50; 95% CI 0.23, 1.06). The key limitations of this review were the small sample size, limited data for secondary outcomes and a lack of standardised method for measuring blood loss. TXA use reduces blood loss in meningioma surgery, but not transfusion requirement or postoperative complications. Larger trials are required to investigate the impact of TXA on patient-reported postoperative outcomes.
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Affiliation(s)
- Abigail L Clynch
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK.
| | - Conor S Gillespie
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.
| | - George E Richardson
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Mohammad A Mustafa
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Abdurrahman I Islim
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester, UK; Division of Neuroscience and Experimental Psychology, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Sumirat M Keshwara
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Ali Bakhsh
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Siddhant Kumar
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Rasheed Zakaria
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Christopher P Millward
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Samantha J Mills
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neuroradiology, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Andrew R Brodbelt
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Michael D Jenkinson
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
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A systematic review and meta-analysis of the effects of tranexamic acid in surgical procedure for intracranial meningioma. J Neurooncol 2023; 161:383-393. [PMID: 36633801 DOI: 10.1007/s11060-023-04237-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
PURPOSE During intracranial meningioma surgery, surgeons experience considerable blood loss. Tranexamic acid (TXA) is used to minimize blood loss in several neurosurgical settings. However, evidence and trials are lacking. Our objective is to establish the most recent evidence on TXA safety and efficacy in intracranial meningioma surgery. METHODOLOGY Based upon Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors collected fully published English literature on the administration of tranexamic acid for patients undergoing intracranial meningioma surgery using the keywords ["tranexamic acid" and "meningioma"] and its synonyms from Cochrane Central Database, the WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, and PubMed. The primary outcome of the current study was total blood loss. The secondary outcomes include individuals requiring blood transfusion, anesthesia duration, surgical duration, and complication rate. Each included studies' quality was assessed using the JADAD scale. RESULTS For qualitative and quantitative data synthesis, we included five RCTs (n = 321) with the mean age was 47.5 ± 11.9 years for the intervention group and 47.2 ± 11.9 years for the control group. Our meta-analysis showed that the administration of TXA is associated with decreased total blood loss of standardized mean difference (SMD) of -1.40 (95% CI [-2.49, -0.31]), anesthetic time SMD -0.36 (95% CI [-0.63, -0.09]), and blood transfusion requirements RR 0.58 (95% CI [0.34, 0.99]). CONCLUSIONS The current study showed that TXA was associated with reduced intraoperative blood loss and intra- and postoperative blood transfusion. However, the studies are small. More RCT studies with a greater sample size are favorable.
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Effectiveness of Super-selective Embolization for Parasagittal Meningiomas and Its Effect on the Level of Inflammatory Factors. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:2466007. [PMID: 35958916 PMCID: PMC9359819 DOI: 10.1155/2022/2466007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/14/2022]
Abstract
Objective To evaluate the effectiveness of super-selective embolization for parasagittal meningiomas and its effect on the level of inflammatory factors. Methods A total of 48 patients with parasagittal meningiomas diagnosed and treated in our hospital from September 2018 to March 2020 were randomly included and assigned to receive meningioma resection (control group) or meningioma resection plus super-selective embolization (study group), with 24 patients in each group. Outcome measures included clinical indices, tumor resection outcome, inflammatory factor levels, and follow-up results. Results Patients in the study group had shorter operative time and less intraoperative bleeding volume than those in the control group (P < 0.05). The study group had more patients with Simpson I resection (87.50%) than the control group (62.50%) (P < 0.05). There was no statistically significant difference in the levels of inflammatory factors between the two groups of patients before treatment (P > 0.05). After treatment, the levels of interleukin (IL)-6, tumor necrosis factor (TNF)-α, and hypersensitive C-reactive protein (hs-CRP) in patients in the study group were significantly lower than those of the control group. The results of the three-month follow-up showed that one patient in the study group was reoperated for tumor recurrence and there was no death record, while three patients in the control group were reoperated for tumor recurrence and one patient died. The difference in the recurrence and mortality between the two groups did not come up to the statistical standard (P > 0.05). Conclusion Super-selective embolization for parasagittal meningiomas contributes to reducing intraoperative bleeding, effectively improving tumor resection and surgical safety, and lowering inflammatory factor levels. Further trials are, however, required before clinical promotion.
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