Chemical venous thromboembolism prophylaxis in neurosurgical patients: an updated systematic review and meta-analysis

Surgeon-led improvement in compliance with use of sequential compression devices in a neurosurgery patient population

INTRODUCTION

Sequential compression devices (SCDs) are the mainstay of mechanical prophylaxis for venous thromboembolism in perioperative neurosurgical patients and are especially crucial when chemical prophylaxis is contraindicated.

OBJECTIVES

This study aimed to characterise and improve SCD compliance in neurosurgery stepdown patients.

METHODS

SCD compliance in a neurosurgical stepdown unit was tracked across 13 months (August 2022-August 2023). When not properly functioning, the missing element was documented. Compliance was calculated daily in all patients with SCD orders, and then averaged monthly. Most common barriers to compliance were identified. With nursing, we implemented a best practice alert to facilitate nursing education at month 3 and tracked compliance over 9 months, with two breaks in surveillance. At month 12, we implemented a patient-engagement measure through creating and distributing a patient-directed infographic and tracked compliance over 2 months.

RESULTS

Compliance averaged 19.7% (n=95) during August and 38.4% (n=131) in September. After implementing the best practice alert and supply chain upgrades, compliance improved to 48.8% (n=150) in October, 41.2% (n=104) in March and 45.9% (n=76) in April. The infographic improved compliance to 51.4% (n=70) in July and 55.1% (n=34) in August. Compliance was significantly increased from baseline in August to October (z=4.5838, p<0.00001), sustained through March (z=3.2774, p=0.00104) and further improved by August (z=3.9025, p=0.0001).

CONCLUSION

Beyond an initial Hawthorne effect, implementation of the best practice nursing alert facilitated sustained improvement in SCD compliance despite breaks in surveillance. SCD compliance nonetheless remained below 50% until implementation of patient-engagement measures which were dependent on physician involvement.

From data to practice: brain meningioma treatment in elderly patients - a survey of the Italian Society of Neurosurgery (SINch®) and systematic review and meta-analysis

The management of meningioma in elderly patients (MEP) presents a complex and evolving challenge. Data available offer conflicting information on treatment options and complications. This survey aimed to examine the current approach to MEP, comparing the national profile to data in the current literature. A survey addressing the treatments options and management of meningioma in elderly was designed on behalf of SINch® (Società Italiana di Neurochirurgia) and sent via email to all Chiefs of Neurosurgical Departments. The survey remained open for responses from May 5th, 2022, until November 21st, 2022. A search of the literature published between January 2000 and March 2023, in accordance to PRISMA guidelines, was included. A total of 51 Neurosurgical centers participated in the survey. The caseload profile of each center influences the choice of treatment selection (Stereotactic Radiosurgery versus open surgery) (p = 0.01) and the consolidated practice of discussing cases within a multidisciplinary group (p = 0.02). The pooled meta-analysis demonstrated a significant increased risk in the elderly group for permanent deficits (p < 0.00001), postoperative infections (p = 0.0004) and hemorrhage (p = 0.0001), perioperative mortality (p < 0.00001), and medical complications (p < 0.00001) as compared to the young population. This study presents the initial comprehensive analysis of the existing trends in the surgical management of MEP in Italy. The significant variation in practices primarily stems from the absence of standardized guidelines. While most centers have adopted an integrated approach, there is a need to promote a multidisciplinary care model. Prospective studies are needed to gather robust evidence in this clinical setting.

The safety of early pharmacological venous thromboembolism prophylaxis in patients with traumatic intracranial haemorrhage: a systematic review and meta-analysis

INTRODUCTION

In patients with traumatic intracranial haemorrhage (tICH) there is significant risk of both venous thromboembolism (VTE) and haemorrhage progression. There is a paucity of literature to inform the timing of pharmacological thromboprophylaxis (PTP) initiation.

AIM

This meta-analysis aims to summarise the current literature on the timing of PTP initiation in tICH.

METHODS

This meta-analysis followed the Methodological Expectations of Cochrane Intervention Reviews checklist and the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Following the literature search, studies were matched against the criteria for inclusion. Data from included studies was pooled, analysed using random-effect analysis and presented as forest plots of risk ratios, except one result reported as difference of means. The ROBINS-I tool was used to assess the risk of bias in the studies. The GRADE approach was taken to assess the quality of included studies. Heterogeneity of studies was assessed using Tau∧2. Funnel plots were generated and used in conjunction with Harbord's test and Rucker's arcsine to assess for small-study effect including publication bias.

RESULTS

A total of 9927 ICH patients who received PTP were included from 15 retrospective observational cohort studies, 4807 patients received early PTP, the remaining 5120 received late PTP. The definition of early was dependent on the study but no more than 72-hours after admission. The mean age of the included cohort was 45.3 (std dev ±9.5) years, and the proportion of males was 71%. Meta-analysis indicated that there was a significant difference between early and late groups for the rate of VTE (RR, 0.544; p = 0.000), pulmonary embolus (RR, 0.538; p = 0.004), deep vein thrombosis (RR, 0.484; p = 0.000) and the intensive care unit length of stay (difference of means, -2.021; 95% CI, -2.250, -1.792; p = 0.000; Tau∧2 = 0.000), favouring the early group. However, the meta-analysis showed no significant difference between the groups for the rate of mortality (RR, 1.008; p = 0.936), tICH progression (RR, 0.853; p = 0.157), and neurosurgical intervention (RR, 0.870; p = 0.480).

CONCLUSION

These findings indicated that early PTP appears to be safe and effective in patients with tICH.

Venous thromboembolism chemical prophylaxis after skull base surgery

PURPOSE

There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis.

METHODS

Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons.

RESULTS

One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM.

CONCLUSION

Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.

Factors related to morbidity and mortality of meningiomas resection‑associated venous thromboembolism (Review)

Patients undergoing intracranial meningioma removal have been reported to have an increased risk of venous thromboembolism (VTE). The present study aimed to study meningioma operations and ascertain rates of postoperative VTE more closely and to find out the associated parameters with VTE-related morbidity and mortality in meningioma patients following resection. This meta-analysis included articles involving meningiomas surgery and postoperative VTE [thromboembolic complications: deep venous thrombosis (DVT) and pulmonary embolism (PE)] published in full-text form between January 1980 and January 2021). Collected variables included: First author name, study period covered, publication year, total number of patients and age, number of males, surgical duration, body mass index (BMI), tumor location, proliferation marker for human tumor cells Ki-67 and VTE-related morbidity and mortality. After the initial search and applying all exclusion and inclusion criteria, five articles were left in the final article pool. The total number of patients was 6,505 who underwent surgery for meningiomas and 299 (4.5%) revealed postoperative VTE. The final results showed no potentially significant difference between the total sample and the postoperative VTE group in tumor location and proliferation marker Ki-67 for human cells. By contrast, the results of the analysis for surgical duration and BMI showed a statistically significant difference. Patients who had experienced open surgery for meningiomas were associated with postoperative VTE. Furthermore, surgical duration and BMI were statistically significant VTE-related parameters in patients who underwent meningioma surgery, showing an association with VTE-related morbidity and mortality.

Thromboprophylaxis practices in neurocritical care-A cross-sectional survey among neurocritical care practitioners

Background and Aims

Thromboprophylaxis practice patterns are quite diverse in neurocritical care patients. The risk of venous thromboembolism remains high in this group due to prolonged immobilised status, extended length of stay and multiple comorbidities. The aim was to comprehend the thromboprophylaxis practices among neurocritical care practitioners in India.

Methods

The cross-sectional online questionnaire-based survey was undertaken among the neurocritical care practitioners. Two investigators framed two sets of 15 questions in the first stage and reviewed them with experts. In the second stage, a set of 22 questions was prepared by a third investigator and pretested among ten experts. The questions were emailed to the participants with a link to the survey. The responses were analysed using Statistical Package For The Social Sciences software.

Results

Of the 185 responses, 53% reported that thromboprophylaxis is practised less often in neurocritical care than in general critical care. The usage of pharmacoprophylaxis among neurosurgical cases, traumatic brain injuries and brain strokes varies widely. There was a preference to use pharmacoprophylaxis in patients with Glasgow Coma Scale (GCS) below nine among many (68.2%), and low molecular weight heparin (LMWH) was the preferred choice in such cases. The reluctance to use heparin because of fear of bleed was high (82%). Most (78.9%) believed pharmacoprophylaxis could reduce venous thromboembolic events (VTEs) and mortality.

Conclusion

Thromboprophylaxis practices among neurocritical care patients remain quite heterogeneous. There is a dilemma in patients with intracranial haemorrhagic lesions regarding pharmacoprophylaxis.

Stratifying the risks of venous thromboembolism in the lateral skull base surgery using Caprini risk assessment model

PURPOSE

To analyze and stratify the possible risk factors of venous thromboembolism (VTE) in lateral skull base surgery (LSBS) using the Caprini risk assessment model.

METHODS

In a single center, a retrospective study was conducted with patients who underwent LSBS from June 2016 to August 2021. The clinical characteristics and blood chemistry tests were collected. The incidence of VTE within 30 days of surgery was recorded. The Caprini risk score was calculated to assess the postoperative VTE risk.

RESULTS

Among the 123 patients in this study, the VTE incidence within 30 postoperative days was 8.9%. The total Caprini risk score in VTE patients (5.6 ± 1.9 points) was significantly higher than that of non-VTE patients (4.6 ± 1.4 points; p = 0.028). The binary logistic regression showed the total Caprini score as the only independent indicator of postoperative VTE. The receiver operating characteristic curve analysis showed that the Caprini score at 6.5 points had low sensitivity (36.4%) but high specificity (91.1%), with the largest area under the curve being 0.659. The VTE rate was significantly higher in patients with a total Caprini score ≥ 7 points (28.6%) compared to those with a total Caprini score ≤ 6 points (7.3%; p = 0.022).

CONCLUSION

LSBS patients have a high risk of developing postoperative VTE. Patients with a Caprini score ≥ 7 points had a significantly higher risk of developing VTE after LSBS. The Caprini risk system was useful in assessing the VTE risk in LSBS. However, more data, calibration, and validation are necessary to establish an exclusive Caprini risk system for LSBS.

Machine learning prediction of venous thromboembolism after surgeries of major sellar region tumors

PURPOSE

To describe and predict the risk of venous thromboembolism (VTE) after surgical resection of major sellar region tumors.

METHOD

Patients with sellar region tumors were identified from a database. The outcome was VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE) within 60 days after surgery. We trained regression and machine learning models to predict the outcome using baseline characteristics, surgical findings and postoperative laboratory tests.

RESULTS

Among 3818 patients included, 124 patients developed VTE after surgery. The total 60-day VTE incidence was 3.2 %, with incidence peak within ten days after the surgery. The risk increased in patients >65 years old (OR 2.96, p < 0.001), in patients with chordoma (OR 3.40, p = 0.006) or craniopharyngioma (OR 1.86, p = 0.036), in patients underwent craniotomy approach (OR 2.78, p = 0.017), in patients with high volume CSF leakage (OR 4.24, p < 0.001), and in patients with longer surgical duration (OR 1.78, p = 0.029). The linear discriminant analysis algorithm had the highest AUC (0.869, 95%CI, 0.840-0.898) in predicting the outcome. The specificity, accuracy, and sensitivity of the best model were 61.8 %, 93.6 %, and 92.8 %, respectively. Risk stratification using our best model suggested that 1.3 % and 24.5 % of the patient developed VTE in the low-risk group and in the high-risk group, respectively. We developed an online decision-support tool available on https://deepvep.shinyapps.io/VTEpred/.

CONCLUSION

The overall incidence of VTE after surgical resection of major sellar region tumors was clinically significant, especially in older patients with chordoma or craniopharyngioma.

Vascular complications in patients with brain tumors

PURPOSE OF REVIEW

Venous thromboembolism (VTE) and other vascular events are common in patients with brain tumors, but their optimal management is not firmly established, in large part due to the competing risk of intracranial hemorrhage (ICH) in this population.

RECENT FINDINGS

There is conflicting evidence on whether therapeutic anticoagulation increases the risk of ICH in patients with brain tumors, with several metanalysis and retrospective cohort studies showing an increased risk and others showing no differences. Current guidelines recommend anticoagulating brain tumors patients with VTE with either low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), and several retrospective studies have shown the risk of ICH with DOACs is similar or smaller than with LMWH.

SUMMARY

An increased risk of VTE exists in a variety of brain tumor types. Most patients with brain tumors and VTE should receive therapeutic anticoagulation, and recent retrospective evidence supports the use of both LMWH and DOACs as effective and relatively safe in this setting. Patients with brain tumors are also at increased risk of other vascular tumor- or treatment-related complications whose optimal management is unclear.

A novel risk score to predict deep vein thrombosis after spontaneous intracerebral hemorrhage

Background and purpose

Studies showed that patients with hemorrhagic stroke are at a higher risk of developing deep vein thrombosis (DVT) than those with ischemic stroke. We aimed to develop a risk score (intracerebral hemorrhage-associated deep vein thrombosis score, ICH-DVT) for predicting in-hospital DVT after ICH.

Methods

The ICH-DVT was developed based on the Beijing Registration of Intracerebral Hemorrhage, in which eligible patients were randomly divided into derivation (60%) and internal validation cohorts (40%). External validation was performed using the iMCAS study (In-hospital Medical Complication after Acute Stroke). Independent predictors of in-hospital DVT after ICH were obtained using multivariable logistic regression, and β-coefficients were used to generate a scoring system of the ICH-DVT. The area under the receiver operating characteristic curve (AUROC) and the Hosmer–Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively.

Results

The overall in-hospital DVT after ICH was 6.3%, 6.0%, and 5.7% in the derivation (n = 1,309), internal validation (n = 655), and external validation (n = 314) cohorts, respectively. A 31-point ICH-DVT was developed from the set of independent predictors including age, hematoma volume, subarachnoid extension, pneumonia, gastrointestinal bleeding, and length of hospitalization. The ICH-DVT showed good discrimination (AUROC) in the derivation (0.81; 95%CI = 0.79–0.83), internal validation (0.83, 95%CI = 0.80–0.86), and external validation (0.88; 95%CI = 0.84–0.92) cohorts. The ICH-DVT was well calibrated (Hosmer–Lemeshow test) in the derivation (P = 0.53), internal validation (P = 0.38), and external validation (P = 0.06) cohorts.

Conclusion

The ICH-DVT is a valid grading scale for predicting in-hospital DVT after ICH. Further studies on the effect of the ICH-DVT on clinical outcomes after ICH are warranted.

A risk prediction model for evaluating thrombosis extension of muscle calf venous thrombosis after craniotomy

Objective

To explore the risk factors of muscle calf venous thrombosis (MCVT) after craniotomy and construct a risk prediction model, so as to provide tool for evaluating the prognosis of MCVT after craniotomy.

Methods

Retrospective analysis was performed on the data of patients undergoing craniotomy complicated with MCVT from January 1, 2018 to December 31, 2020. A prediction model was established by Logistic regression, and the predictive efficacy of the model was tested by ROC curve. The accuracy of the risk model was evaluated by Hosmer-Lemeshow (H-L) test, and the model was verified internally by cross validation.

Results

Among the 446 patients who underwent craniotomy complicated with MCVT, 112 cases (25.11%) had thrombosis extension. D-dimer, Capirini scores, length of hospital stay, malignant tumor, fracture, use of dehydrating agents and hemostatic agents were independently related to thrombosis extension after craniotomy. The area under ROC curve (AUROC) of the prediction model was 0.918 (0.888, 0.942), and the sensitivity and specificity of the maximum Youden index were 85.3% and 78.2%, respectively. H-L test showed that the prediction model was accurate (χ² = 12.426, P = 0.133). The internal verification results of the prediction model showed that the AUROC value of the prediction model is 0.892.

Conclusion

The prediction model has a good prediction efficacy on the prognosis of post-craniotomy patients complicated with MCVT, and can be used as a tool to evaluate the risk of thrombosis extension.

Neurosurgical enhanced recovery after surgery ERAS for geriatric patients undergoing elective craniotomy: A review

Population aging is an unprecedented, multifactorial, and global process that poses significant challenges to healthcare systems. Enhanced recovery after surgery (ERAS) protocols aim to optimize perioperative care. The first neurosurgical ERAS protocol for elective craniotomy has contributed to a shortened postoperative hospital stay, accelerated functional recovery, improved patient satisfaction, and reduced medical care cost in adult patients aged 18 to 65 years compared with conventional perioperative care. However, ERAS protocols for geriatric patients over 65 years of age undergoing cranial surgery are lacking. In this paper, we propose a novel ERAS protocol for such patients by reviewing and summarizing the key elements of successful ERAS protocols/guidelines and optimal perioperative care for geriatric patients described in the literature, as well as our experience in applying the first neurosurgical ERAS protocol for a quality improvement initiative. This proposal aimed to establish an applicable protocol for geriatric patients undergoing elective craniotomy, with evidence addressing its feasibility, safety, and potential efficacy. This multimodal, multidisciplinary, and evidence-based ERAS protocol includes preoperative, intraoperative, and postoperative assessment and management as well as outcome measures. The implementation of the current protocol may hold promise in reducing perioperative morbidity, enhancing functional recovery, improving postoperative outcomes in geriatric patients scheduled for elective craniotomy, and serving as a stepping stone to promote further research into the advancement of geriatric patient care.

Pharmacological venous thromboembolism prophylaxis in elective cranial surgery: a systematic review of time of initiation, regimen and duration

INTRODUCTION

Pharmacological prophylaxis of venous thromboembolism (VTE) requires nuanced decision-making to balance the risk of VTE against haemorrhage. This problem is compounded in neurosurgical patients, in whom postoperative intracranial haemorrhage (ICH) may be catastrophic, compared to non-neuraxial bleeding in other types of surgery. Current major guidelines recommend caution when using pharmacological prophylaxis in elective cranial surgery, but incorporate low-quality evidence and lack precise guidance on timing and duration of anticoagulation.

METHODS

We aimed to answer the following questions for patients undergoing elective cranial surgery: (1) when is the optimal time to initiate postoperative anticoagulation, and (2) how long should postoperative anticoagulation be continued for? In this systematic review, we screened randomised and non-randomised studies reporting original data on pharmacological VTE prophylaxis in elective cranial surgery. Outcomes of interest were VTE and ICH.

RESULTS

Three retrospective, single-centre observational studies met eligibility criteria, with a total of 923 participants. Meta-analysis was not performed due to a high risk of bias across all studies. Through narrative synthesis, we found that patients who developed VTE were significantly more likely to receive their first postoperative dose at a later time (mean: 144 vs. 29 h, p = .04). Shorter courses of anticoagulation (<7 days) were associated with significantly lower ICH rates (p = .03) compared to longer courses (>21 days).

CONCLUSION

The limited evidence favours earlier initiation and shorter courses of thromboprophylactic anticoagulation. These findings are specific to patients undergoing surgery for meningioma or glioma and may not apply to other populations. Randomised controlled trials or robustly designed observational studies are necessary to establish a clearer evidence base.

Venous thromboembolism chemical prophylaxis after endoscopic trans-sphenoidal pituitary surgery

PURPOSE

There is no compelling outcome data or clear guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using low molecular weight heparin (chemoprophylaxis) in patients undergoing pituitary surgery. Here we describe our experience of early chemoprophylaxis (post-operative day 1) following trans-sphenoidal pituitary surgery.

METHODS

Single-centre review of a prospective surgical database and VTE records. Adults undergoing first time trans-sphenoidal pituitary surgery were included (2009-2018). VTE was defined as either deep vein thrombosis and/or pulmonary embolism within 3 months of surgery. Postoperative haematomas were those associated with a clinical deterioration together with radiological evidence.

RESULTS

651 Patients included with a median age of 55 years (range 16-86 years). Most (99%) patients underwent trans-sphenoidal surgery using a standard endoscopic single nostril or bi-nostril trans-sphenoidal technique. More than three quarters had pituitary adenomas (n = 520, 80%). Postoperative chemoprophylaxis to prevent VTE was administered in 478 patients (73%). Chemoprophylaxis was initiated at a median of 1 day post-procedure (range 1-5 days postoperatively; 92% on postoperative day 1). Tinzaparin was used in 465/478 patients (97%) and enoxaparin was used in 14/478 (3%). There were no cases of VTE, even in 78 ACTH-dependent Cushing's disease patients. Six patients (1%) developed postoperative haematomas. Chemoprophylaxis was not associated with a significantly higher rate of postoperative haematoma formation (Fisher's Exact, p = 0.99) or epistaxis (Fisher's Exact, p > 0.99).

CONCLUSIONS

Chemoprophylaxis after trans-sphenoidal pituitary surgery on post-operative day 1 is a safe strategy to reduce the risk of VTE without significantly increasing the risk of postoperative bleeding events.

Venous Thrombotic Events and Anticoagulation in Brain Tumor Patients

PURPOSE OF REVIEW

Brain tumor patients have a 20-30% risk of venous thromboembolism (VTE), with management complicated by risk of intracranial hemorrhage (ICH). Here we review the epidemiology, pathogenesis, and recommended management of VTE in brain tumors.

RECENT FINDINGS

New risk factors and molecular mechanisms of VTE in brain tumor patients have emerged, including the protective effect of IDH mutation in gliomas and the potential role of podoplanin-mediated platelet aggregation in thrombogenesis in these tumors. Recent studies show that the risk of ICH is not significantly higher in brain tumor patients receiving anticoagulation. Based on systemic cancer trials, direct oral anticoagulants (DOACs) may be a suitable alternative to traditional heparin treatment, but the applicability of these findings to brain tumors is unclear. Anticoagulation is indicated in the treatment of VTE for brain tumor patients, and appears to be reasonably safe; based on retrospective evidence, DOACs may be a reasonable agent.

[The new algorithm for stratification of the risk of venous thromboembolic events in elective neurosurgery and its prognostic significance]

Early identification of risk groups is essential for effective and target prevention of venous thromboembolic events (VTE) in all areas of surgery. For this purpose, the authors has developed and put into practice an algorithm distinguishing the groups of low, moderate and high risk of VTE among neurosurgical patients.

OBJECTIVE

To assess predictive value of the developed algorithm for elective neurosurgical interventions.

MATERIAL AND METHODS

The study included 7914 patients who underwent surgery between January 2018 and December 2019. According to the algorithm, we identified the groups of low (1536 (19%) patients), moderate (4554 (58%) patients) and high risk (1824 (23%) patients). Moreover, patients were divided into subgroups depending on surgical procedure. We analyzed the incidence of VTE and mortality in all groups.

RESULTS. INCIDENCE

Of VTE with a 95% confidence interval in the low-risk group was 0.65% [0.26; 1.04], in the moderate risk group - 1.82% [1.47; 2.24], in the high-risk group - 12.61% [11.02; 14.09]. When comparing various surgical interventions, we revealed more common VTE after vascular microsurgery (15.62%), in patients with brain tumors (12.63%) and spinal cord tumors (6.52%).

CONCLUSION

The risk stratification algorithm has demonstrated its convenience and significant predictive value for determining the risk of VTE among elective neurosurgical patients. In addition, different incidence of VTE was demonstrated in patients with various neurosurgical diseases.

Rate of Development of Venous Thromboembolism in Lateral Skull Base Surgery

OBJECTIVES

Venous thromboembolism (VTE) is a major cause of morbidity and mortality for surgical patients. This article aims to determine factors that may have contributed to the development of VTE in patients undergoing lateral skull base surgery, to assess the validity of the Caprini Risk Assessment Model (RAM) score in this subset of patients, and to determine the efficacy of mechanical DVT prophylaxis alone in preventing VTE.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review was conducted of patients who underwent skull base surgery for vestibular schwannoma, and the rate of VTE was assessed. Patient demographics, comorbidities, and treatment factors were examined to determine risk factors associated with the development of a postoperative thrombotic event. Caprini RAM scores were compared for patients who developed a VTE.

RESULTS

Among 197 patients, the rate of VTE formation was 3.5%. No individual risk factor independently contributed to the development of a thrombotic event. The mean Caprini RAM score was 4.06 in patients who did not develop a VTE and 5.14 in the patients that did develop a VTE (P = .005). The Caprini score was significant for the risk of VTE formation, with an odds ratio of 2.8 (P = .009, 95% CI = 1.3-6.2).

CONCLUSION

Venous thromboembolism rates are relatively low following lateral skull base surgery. While there is no individual risk factor associated with increased VTE risk, the Caprini RAM score appears to be a useful predictor of risk. The Caprini score may be useful in identifying high-risk patients who may benefit from chemoprophylaxis for VTE prevention.

LEVEL OF EVIDENCE

Level III-This is a retrospective chart review study Laryngoscope, 2021.

The risks and benefits of early venous thromboembolism prophylaxis after elective spinal surgery: A single-centre experience

BACKGROUND

There is a wide ranging incidence of venous thromboembolism after surgery and it continues to be a major cause of morbidity after spinal procedures.This study's aim was to investigate the relationship between timing and administration of venous thromboembolism (VTE) pharmacologic chemoprophylaxis after spinal surgery and the resulting VTE and bleeding complications by reviewing current practices and outcomes at a high-volume single institution to better define opportunities for perioperative intervention to prevent VTE without increasing bleeding complications.

METHODS

All patients who underwent elective one or two-stage lumbar spinal fusion procedures were identified. A logistic regression was used to evaluate (1) risk of symptomatic VTE within 30 days of surgery and (2) bleeding-related complications. The odds of developing a VTE as well as bleeding-related complications were compared among the three treatment groups: no chemoprophylaxis, chemoprophylaxis < 24h of surgery and chemoprophylaxis given > 24h post-surgery.

RESULTS

When adjusted for doses administered, the odds of developing a postoperative VTE within 30 days were 0.189 (95% confidence interval (0.044, 0.808)) in patients who received anticoagulation < 24h postoperatively, compared to those who received no anticoagulation (p = 0.025). There was no difference in bleeding rates.

CONCLUSION

Patients undergoing elective spinal surgery who received anticoagulation within 24h of the conclusion of their procedure had an 81% reduction in the odds of developing a deep vein thrombosis within 30 days with no significant difference in bleeding complications.

Early chemoprophylaxis for deep venous thrombosis does not increase the risk of hematoma expansion in patients presenting with spontaneous intracerebral hemorrhage

Background:

Spontaneous intracerebral hemorrhage (ICH) is a significant cause of morbidity and mortality worldwide. The development of venous thromboembolism (VTE), including deep venous thrombosis or pulmonary embolism, is correlated with negative outcomes following ICH. Due to the risk of hematoma expansion associated with the use of VTE chemoprophylaxis, there remains significant debate about the optimal timing for its initiation following ICH. We analyzed the risk of early chemoprophylaxis on hematoma expansion following ICH.

Methods:

We performed a retrospective analysis of patients presenting with spontaneous ICH at single institution between 2011 and 2018. The rate of hematoma expansion was compared between patients that received early chemoprophylaxis (on admission) and those that received conventional chemoprophylaxis (>24 h).

Results:

Data for 235 patients were available for analysis. Eleven patients (7.5%) in the early prophylaxis cohort and seven patients (8.0%) in the conventional prophylaxis cohort developed VTE (P = 0.9). Hematoma expansion also did not differ significantly (early 19%, conventional 23%, P = 0.5).

Conclusion:

The use of early chemoprophylaxis against venous thromboembolic events following ICH appears safe in our patient population without increasing the risk of hematoma expansion. Given the increased risk of poor outcome in the setting of VTE, early VTE chemoprophylaxis should be considered in patients who present with ICH. Larger, prospective, and randomized studies are necessary to better elucidate the risk of early chemoprophylaxis and potential reduction in venous thromboembolic events.

[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.

Posterior Fossa Hemorrhage Following the Use of Low-Molecular-Weight Heparin: Lessons Learned and Recommendations for the Treatment and Prophylaxis of Postoperative Venous Thromboembolism

Introduction Venous thromboembolism (VTE) is the most common preventable cause of morbidity and mortality among neurosurgery patients. Several studies have concluded that the use of chemical prophylaxis among patients undergoing a craniotomy reduces the incidence of VTE, and it is presumed to be safe. However, these studies do not differentiate between a supratentorial and posterior fossa craniotomy. Furthermore, the prophylactic or therapeutic use of low-molecular-weight heparin (LMWH) has been reported to increase the risk of intracranial hemorrhage. In this study, we describe the clinical details and outcomes for all patients who underwent posterior fossa craniotomy and developed posterior fossa hemorrhage secondary to postoperative use of LMWH during the study period. We also propose recommendations pertaining to postoperative heparin use after posterior fossa surgeries. Methods Data were retrospectively collected for patients presenting with posterior fossa hemorrhage following anticoagulant use among those who previously underwent posterior fossa craniotomy by the senior author (R.W.P.) from January 1, 2011, through December 31, 2018. Results We identified five patients who experienced postoperative hemorrhage while receiving LMWH in the initial setting of posterior fossa craniotomy. After hemorrhaging, four patients had low Glasgow Outcome Scale (GOS) scores (≤3) and failed to return to their baseline neurological status. These four patients had a Glasgow Coma Scale (GCS) score of 15/15 in the immediate postoperative period and received heparin within 72 hours of surgery. Conclusions Based on our findings, there is a possible association between the increased risk of hemorrhage and the early postoperative use of LMWH. The debilitating outcomes among the majority of these patients warrant the cautious use and further investigation of postoperative LMWH to appropriately quantify the risk. Further comparative studies with a larger sample size are required to provide insight into the pathophysiology of our findings.

Pharmacologic thromboprophylaxis in adult patients undergoing neurosurgical interventions for preventing venous thromboembolism

The impact of pharmacologic prophylaxis for venous thromboembolism in patients undergoing neurosurgical intervention remains uncertain. We reviewed the efficacy and safety of pharmacologic compared with nonpharmacologic thromboprophylaxis in neurosurgical patients. Three databases were searched through April 2018, including those for randomized controlled trials (RCTs) and for nonrandomized controlled studies (NRSs). Independent reviewers assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Seven RCTs and 3 NRSs proved eligible. No studies reported on symptomatic proximal and distal deep vein thrombosis (DVT). Two RCTs reported on screening-detected proximal and distal DVTs. We used the findings of these 2 RCTs as the closest surrogate outcomes to inform the proximal and distal DVT outcomes. These 2 RCTs suggest that pharmacologic thromboprophylaxis may decrease the risk of developing asymptomatic proximal DVT (relative risk [RR], 0.50; 95% confidence interval [CI], 0.30-0.84; low certainty). Findings were uncertain for mortality (RR, 1.27; 95% CI, 0.57-2.86; low certainty), symptomatic pulmonary embolism (PE) (RR, 0.84; 95% CI, 0.03-27.42; very low certainty), asymptomatic distal DVT (RR, 0.54; 95% CI, 0.27-1.08; very low certainty), and reoperation (RR, 0.43; 95% CI, 0.06-2.84; very low certainty) outcomes. NRSs also reported uncertain findings for whether pharmacologic prophylaxis affects mortality (RR, 0.72; 95% CI, 0.46-1.13; low certainty) and PE (RR, 0.18; 95% CI, 0.01-3.76). For risk of bleeding, findings were uncertain in both RCTs (RR, 1.57; 95% CI, 0.70-3.50; low certainty) and NRSs (RR, 1.45; 95% CI, 0.30-7.12; very low certainty). In patients undergoing neurosurgical procedures, low certainty of evidence suggests that pharmacologic thromboprophylaxis confers benefit for preventing asymptomatic (screening-detected) proximal DVT with very low certainty regarding its impact on patient-important outcomes.

Bundled Payment Models in Spine Surgery

STUDY DESIGN

The following is a narrative discussion of bundled payments in spine surgery.

OBJECTIVE

The cost of healthcare in the United States has continued to increase. To lower the cost of healthcare, reimbursement models are being investigated as potential cost saving interventions by driving incentives and quality improvement in fields such a spine surgery.

METHODS

Narrative overview of literature pertaining to bundled payments in spine surgery synthesizing findings from computerized databases and authoritative texts.

RESULTS

Spine surgery is challenging to define payment modes because of high cost variability and surgical decision-making nuances. While implementing bundled care payments in spine surgery, it is important to understand concepts such as value-based purchasing, episodes of care, prospective versus retrospective payment models, one versus two-sided risk, risk adjustment, and outlier protection. Strategies for implementation underscore the importance of risk stratification and modeling, adoption of evidence based clinical pathways, and data collection and dissemination. While bundled care models have been successfully implemented, challenges facing institutions adopting bundled care payment models include financial stressors during adoption of the model, distribution of risks, incentivization of treating only low risk patients, and nuanced variation in procedures leading to variation in costs.

CONCLUSION

An alternative for fee for service payments, bundled care payments may lead to higher cost savings and surgeon accountability in a patient's care.

Comparative efficacy and safety of pharmacological prophylaxis and intermittent pneumatic compression for prevention of venous thromboembolism in adult undergoing neurosurgery: a systematic review and network meta-analysis

Whether intermittent pneumatic compression (IPC) is a more effective form of thromboprophylaxis than anticoagulants in individuals undergoing neurosurgery remains controversial. Relevant studies are sparse and inconsistent. Therefore, direct comparisons are difficult to perform and impractical. Hence, we summarized and compared the efficacy and safety of IPC and anticoagulants for the prevention of venous thromboembolism (VTE) in adults undergoing cranial or spinal procedures. Several electronic databases were searched for randomized controlled trials on the use of IPC and anticoagulants for thromboembolism prevention in neurosurgical patients, from inception to August 6, 2019. Studies reporting the selected endpoints were included in direct and Bayesian network meta-analyses to estimate the relative effects of the interventions. Overall, our analysis included 18 trials comprising 2474 patients. Both IPC (RR, 0.41; 95% CrI, 0.26-0.60) and chemical prophylaxis (RR, 0.48; 95% CrI, 0.28-0.68) were found to be more efficacious than the placebo in reducing the risk of deep vein thrombosis (DVT). In addition, our analysis also demonstrated that both IPC (RR, 0.10; 95% CrI, 0.01-0.60) and chemical prophylaxis (RR, 0.31; 95% CrI, 0.05-1.00) reduced the risk of pulmonary embolism (PE) significantly more than the placebo. Based on the available evidence of moderate-to-good quality, IPC is equivalent to anticoagulants for thromboprophylaxis in terms of efficacy. Evidence to support or negate the use of pharmacological prophylaxis in terms of safety is lacking. The results of ongoing and future large randomized clinical trials are needed.

How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH)

BACKGROUND

Anticoagulant assumption is a concern in neurosurgical patient that implies a delicate balance between the risk of thromboembolism versus the risk of peri- and postoperative hemorrhage.

METHODS

We performed a survey among 129 different neurosurgical departments in Italy to evaluate practice patterns regarding the management of neurosurgical patients taking anticoagulant drugs. Furthermore, we reviewed the available literature, with the aim of providing a comprehensive but practical summary of current recommendations.

RESULTS

Our survey revealed that there is a lack of knowledge, mostly regarding the indication and the strategies of anticoagulant reversal in neurosurgical clinical practice. This may be due a lack of national and international guidelines for the care of anticoagulated neurosurgical patients, along with the fact that coagulation and hemostasis are not simple topics for a neurosurgeon.

CONCLUSIONS

To overcome this issue, establishment of hospital-wide policy concerning management of anticoagulated patients and developed in an interdisciplinary manner are strongly recommended.

Neurologic complications of venous thromboembolism

Patients with neurologic disease are at high risk of venous thromboembolism (VTE). The converse risk of neurological complications in concert or following peripheral VTE is rarely considered. The major neurologic complication following pulmonary embolism or peripheral VTE is intracranial hemorrhage that occurs following anticoagulation therapy for VTE. Ischemic stroke may occur concomitantly with VTE. VT occurrence may also be a marker for a future increased risk of stroke. Peripheral neuropathy may occur or neuropathic pain may occur as a result of thrombophlebitis following deep venous thrombosis. Other sequelae of VTE are somewhat theoretical including the discovery of central nervous system malignancies after incident VTE.

Hypercoagulability in Vestibular Schwannoma Surgery

OBJECTIVE

Patients with vestibular schwannoma who harbor a genetic predisposition for venous thromboembolism require special consideration when determining optimal therapeutic management. The primary objective of the current study was to provide recommendations on treatment of hypercoagulable patients with vestibular schwannoma through a case series and review of the literature.

PATIENTS

Two patients who underwent resection of vestibular schwannomas.

INTERVENTIONS

Surgical resection and diagnostic testing.

MAIN OUTCOME MEASURES

Postoperative venous thromboses.

RESULTS

One patient who underwent resection of vestibular schwannoma and suffered several postoperative thrombotic complications consistent with a clinical thrombophilia. One patient with known Factor V Leiden deficiency who underwent resection of vestibular schwannoma followed by postoperative chemoprophylaxis with a direct factor Xa inhibitor and experienced an uneventful postoperative course.

CONCLUSIONS

In patients with a known propensity for venous thromboembolism, the skull base surgeon should consider nonsurgical management. If the patient undergoes surgical resection, we recommend careful effort to minimize trauma to the sigmoid sinus. In addition, the surgeon may consider retrosigmoid or middle fossa approaches. Best practice recommendations include the use of pneumatic compression devices, early ambulation, and consideration of postoperative prophylactic anticoagulation in patients with a known genetic predisposition.

The Attributable Mortality of Postoperative Bleeding Exceeds the Attributable Mortality of Postoperative Venous Thromboembolism

BACKGROUND

Bleeding and venous thromboembolic disease are considered important sources of postoperative morbidity and mortality. Clinically, treatment of these 2 disorders is often competing. We sought to better understand the relative contributions of bleeding and venous thromboembolic disease to postoperative attributable mortality in a national cohort.

METHODS

A retrospective analysis of the 2006-2017 American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was performed to assess the adjusted odds ratio and attributable mortality for postoperative bleeding and venous thromboembolism, adjusted by year.

RESULTS

After adjustment for confounding variables, bleeding exhibited a high postoperative attributable mortality in every year studied. Venous thromboembolism appeared to contribute minimal attributable mortality.

CONCLUSIONS

Bleeding complications are a consistent source of attributable mortality in surgical patients, while the contribution of venous thromboembolic disease appears to be minimal in this analysis. Further studies are warranted to better understand the etiology of this disparity.

The incidence of venous thromboembolism following surgical resection of intracranial and intraspinal meningioma. A systematic review and retrospective study

INTRODUCTION

Historically, the development of venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary thromboembolism (PE) was cited as a higher post-operative risk for patients harboring meningiomas. However, recent literature has suggested that there may be no elevated risk for VTE among these patients. The authors perform both a retrospective review of their own cases as well as a systematic review of the literature in order to determine the frequency of the VTE and rate of post-operative hemorrhage in this patient population.

METHODOLOGY

Patients undergoing surgery for intracranial and spinal meningioma from 2012 to 2019 were retrospectively reviewed for patient demographics, clinical characteristics, and post-operative complications. Logistic regression was used to determine risk factors for the development of VTE. Additionally, a PubMed search was performed to identify patients addressing this topic.

RESULTS

Our retrospective review included 189 patients who underwent 197 operations. The rate of VTE for patients receiving LMWH was 3.55 % vs. 4.06 % for those not receiving LMWH. There were no observed hemorrhages after initiation of LMWH. Multivariate analysis found tumor volume, history of DVT, and length of hospital stay as independent risk factors for VTE. In the systematic review, 11 papers describing 28,954 patients were included. The risk of developing a VTE with or without LMWH was 2.71 % versus 4.07 %, respectively. The hemorrhage risk was 2.23 % on LMWH versus 4.20 % not on LMWH.

DISCUSSION

In several heterogeneous series of all types of neurosurgical procedures, the reported rate of VTE was 11.1 %. In our review of the literature, the VTE rate of 2.71 % was similar to our cohort's rate of 3.55 %, for patients administered LMWH postoperatively. Higher rates of VTE with meningiomas may not be the case as once thought. Regular use of LMWH appears to be a safe, but it also did not necessarily lower the rates of VTE in our cohort. The use of routine lower-extremity duplex ultrasound, mechanical prophylaxis, and early mobilization, may have contributed to these lower rates of VTEs in patients with meningiomas.

Prolonged activated partial thromboplastin time after prophylactic-dose unfractionated heparin in the post-operative neurosurgical setting: case series and management recommendations

Primary brain tumors, both benign and malignant, pose a high risk of perioperative venous thromboembolism (VTE) due to the development of a prothrombotic state. Perioperative pharmacologic thromboprophylaxis with subcutaneous (SC) unfractionated heparin (UFH) has significantly reduced VTE associated morbidity. Recent reports suggest an association between prolonged activated partial thromboplastin time (aPTT) due to prophylactic SC UFH and increased bleeding risk. We present three patients with normal baseline coagulation parameters in whom pharmacologic thromboprophylaxis with SC UFH resulted in a marked prolongation of the aPTT, leading to adverse outcomes in two patients. These cases demonstrate the uncertain kinetics of SC UFH and effect on aPTT, suggesting the significance of routine aPTT monitoring in high-risk settings. Given the wide variation in presentations of therapeutic or supratherapeutic values of aPTT in the perioperative neurosurgical setting, we propose a practical standardized approach to the evaluation and management of aPTT prolongation following prophylactic SC UFH administration.

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.

Prophylactic unfractionated heparin and hemorrhage in neurocritically ill underweight patients: A case series and review of the literature

PURPOSE

Three cases of major bleeding associated with thromboprophylactic unfractionated heparin (UFH) therapy in underweight neurocritically ill patients are reported.

SUMMARY

Three underweight patients (body mass index of <18.5 kg/m2) were treated in the intensive care unit with major bleeds associated with UFH thromboprophylaxis. Two of the patients, a 76-year-old female and a 56-year-old female, had hemorrhages on presentation; the third patient, a 29-year-old male, developed bleeding during his admission. All 3 patients had past medical histories consisting of acute neurologic conditions within 6 weeks of presentation, including subdural hematoma, subarachnoid hemorrhage, and obstructive hydrocephalus secondary to a brain mass. All hemorrhages developed following the receipt of prophylactic UFH at doses of 5,000 units every 8 to 12 hours, which translated to high weight-based dosages (>300 units/kg/d). Additionally, hemorrhages were associated with prolonged activated partial thromboplastin time, which declined following heparin discontinuation. The major bleeds following UFH administration included an acute on chronic subdural hematoma, acute rectus sheath hematoma, and cerebellar hematoma. Stabilization of the subdural hematoma was achieved without the use of protamine and the patient was discharged in stable condition. The other 2 patients expired secondary to their hemorrhagic events. Naranjo nomogram scores for the patients indicated that heparin was the probable cause of bleed in 2 cases and a possible cause in 1 case.

CONCLUSION

Three major hemorrhages developed following the administration of UFH. Underweight patients with neurologic injury may require increased clinical vigilance, reduced doses, and pharmacodynamic monitoring to improve safety outcomes associated with thromboprophylaxis.

Screening duplex ultrasonography in neurosurgery patients does not correlate with a reduction in pulmonary embolism rate or decreased mortality

OBJECTIVE

Deep vein thrombosis (DVT) is a major focus of patient safety indicators and a common cause of morbidity and mortality. Many practices have employed lower-extremity screening ultrasonography in addition to chemoprophylaxis and the use of sequential compression devices in an effort to reduce poor outcomes. However, the role of screening in directly decreasing pulmonary emboli (PEs) and mortality is unclear. At the University of Mississippi Medical Center, a policy change provided the opportunity to compare independent groups: patients treated under a prior paradigm of weekly screening ultrasonography versus a post-policy change group in which weekly surveillance was no longer performed.

METHODS

A total of 2532 consecutive cases were reviewed, with a 4-month washout period around the time of the policy change. Criteria for inclusion were admission to the neurosurgical service or consultation for ≥ 72 hours and hospitalization for ≥ 72 hours. Patients with a known diagnosis of DVT on admission or previous inferior vena cava (IVC) filter placement were excluded. The primary outcome examined was the rate of PE diagnosis, with secondary outcomes of all-cause mortality at discharge, DVT diagnosis rate, and IVC filter placement rate. A p value < 0.05 was considered significant.

RESULTS

A total of 485 patients met the criteria for the pre-policy change group and 504 for the post-policy change group. Data are presented as screening (pre-policy change) versus no screening (post-policy change). There was no difference in the PE rate (2% in both groups, p = 0.72) or all-cause mortality at discharge (7% vs 6%, p = 0.49). There were significant differences in the lower-extremity DVT rate (10% vs 3%, p < 0.01) or IVC filter rate (6% vs 2%, p < 0.01).

CONCLUSIONS

Based on these data, screening Doppler ultrasound examinations, in conjunction with standard-of-practice techniques to prevent thromboembolism, do not appear to confer a benefit to patients. While the screening group had significantly higher rates of DVT diagnosis and IVC filter placement, the screening, additional diagnoses, and subsequent interventions did not appear to improve patient outcomes. Ultimately, this makes DVT screening difficult to justify.

Incidence and Risk Factors for Venous Thromboembolism Following Craniotomy for Intracranial Tumors: A Cohort Study

Context:

Venous thromboembolism (VTE) is a devastating complication of intracranial tumor surgery. The present study helps identify patients at the greatest risk of developing VTE.

Aims:

The aim of the study was to evaluate the incidence of and risk factors for VTE following craniotomy for intracranial tumors.

Setting and Designs:

This was a retrospective cohort study.

Methods:

Data from the institutional database (between January 2017 and December 2018) were reviewed. Consecutive patients with intracranial tumors who underwent craniotomy were included.

Statistical Analysis Used:

Patient characteristics were reported as descriptive data, and factors associated with VTE development were analyzed by the Cox regression model.

Results:

The study identified 177 patients. The incidence of VTE was 10.2% (deep-vein thrombosis [DVT], 8.5%; pulmonary embolism [PE] 1.7%; and simultaneous DVT and PE, 1.7%). In univariate analysis, VTE development was associated with diabetes mellitus (DM), operative duration of >420 min, blood transfusion, and new-onset postoperative motor deficits. DM and new-onset postoperative motor deficits were statistically significant factors in multivariable analysis, with hazard ratios of 4.52 (95% confidence interval [CI] = 1.38–14.82) and 3.46 (95% CI = 1.17–10.23), respectively.

Conclusions:

Postcraniotomy VTE was detected in 10.2% of patients with intracranial tumors. Risk factors for VTE included DM and new-onset postoperative motor deficits. Hence, intracranial tumor patients with these risk factors are the most likely to require VTE prophylaxis with an anticoagulant.

Venous Thromboembolism After Degenerative Spine Surgery: A Nationwide Readmissions Database Analysis

BACKGROUND

Venous thromboembolism (VTE) is an appreciable burden on health care. The protracted recumbency experienced by many spinal patients juxtaposed with concerns for postoperative hemorrhage from early anticoagulation results in conflicting stances regarding chemoprophylaxis. Identifying risk factors associated with VTE is therefore instrumental in guiding management.

OBJECTIVE

To identify VTE risk factors in patients undergoing degenerative spine surgery.

METHODS

The Nationwide Readmissions Database was searched for adults undergoing spine surgery for degenerative diseases between 2010 and 2014. The 30-day and 90-day VTE incidence was estimated from readmissions with new VTE diagnoses. A multivariate survey-adjusted logistic regression model was used to identify variables associated with VTE diagnoses on readmission.

RESULTS

Of 838,507 degenerative spine cases queried, 3499 patients (0.42%) were readmitted with a VTE diagnosis within 30 days and 4321 patients (0.62%) were readmitted within 90 days. In multivariate analysis, steroids were independently associated with a higher likelihood of readmission with VTE at both 30 days (odds ratio, 1.58; P < 0.001) and 90 days (odds ratio, 1.97; P < 0.001). Significant associations were also identified with thoracolumbar surgery, length of stay, and discharge to institutional care.

CONCLUSIONS

The incidence of readmission with VTE diagnoses in spine surgery is low. However, their devastating consequences underscore the need to identify those patients deemed high risk. These patients include those having thoracolumbar surgery, of advanced age, with prolonged length of stay, using corticosteroids, and with a disposition to institutional care (e.g., skilled nursing facility or long-term acute care). Given the association between steroids and VTE, clinicians should be judicious about perioperative administration despite their obvious antiinflammatory benefits.

Predictors of Venous Thromboembolism After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis

BACKGROUND

Venous thromboembolism (VTE) is responsible for many hospital readmissions each year, particularly among postsurgical cohorts. Because early and indiscriminate VTE prophylaxis carries catastrophic consequences in postcraniotomy cohorts, identifying factors associated with a high risk for thromboembolic complications is important for guiding postoperative management.

OBJECTIVE

To determine VTE incidence in patients undergoing nonemergent craniotomy and to evaluate for factors that predict 30-day and 90-day readmission with VTE.

METHODS

The 2010-2014 cohorts of the Nationwide Readmissions Database were used to generate a large heterogeneous craniotomy sample.

RESULTS

There were 89,450 nonemergent craniotomies that met inclusion criteria. Within 30 days, 1513 patients (1.69%) were readmitted with VTE diagnoses; among them, 678 (44.8%) had a diagnosis of deep vein thrombosis alone, 450 (29.7%) had pulmonary embolism alone, and 385 (25.4%) had both. The corresponding 30-day deep vein thrombosis and pulmonary embolism incidences were 1.19% and 0.93%, respectively. In multivariate analysis, several factors were significantly associated with VTE readmission, namely, craniotomy for tumor, corticosteroids, advanced age, greater length of stay, and discharge to institutional care.

CONCLUSIONS

Craniotomies for tumor, corticosteroids, advanced age, prolonged length of stay, and discharge to institutional care are significant predictors of VTE readmission. The implication of steroids, coupled with their ubiquity in neurosurgery, makes them a potentially modifiable risk factor and a prime target for VTE reduction in craniotomy cohorts. Furthermore, the fact that dose is proportional to VTE risk in the literature suggests that careful consideration should be given toward decreasing regimens in situations in which use of a lower dose might prove equally sufficient.

Severe Leg Pain Following Spinal Cord Stimulator Implantation - A Case Report

Following spinal cord stimulator (SCS) implantation, postoperative pain is commonly incisional or neuropathic from neurological damage. Occasionally, this new pain may mimic symptoms caused by preexisting pathology. This article presents a case of immediate, severe, postoperative leg pain secondary to a lower extremity deep vein thrombosis (DVT) and subsequent pulmonary embolism after percutaneous SCS implantation for failed back syndrome. The risk factors of DVT after spine surgery and perioperative prophylaxis are further discussed with a brief literature review. LEVEL OF EVIDENCE: V.