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Yang J, Wang K, Han C, Liu Q, Zhang S, Wu J, Jiang P, Yang S, Guo R, Mo S, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. Preoperative antiplatelet therapy may be a risk factor for postoperative ischemic complications in intracranial hemorrhage patients. Int J Neurosci 2024; 134:899-905. [PMID: 36503400 DOI: 10.1080/00207454.2022.2157724] [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: 01/14/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hemorrhage (ICH) patients are still at risk of postoperative ischemic complications (PICs) after surgery. In addition, the proportion of patients receiving antiplatelet therapy (APT) in ICH patients increased significantly with age. This study aims to evaluate the impact of preoperative antiplatelet therapy on PICs in ICH patients. METHODS This is a cohort study that retrospectively analyzed the data of ICH patients who underwent surgical treatment. PICs rate was compared between patients with preoperative ATP and those without preoperative ATP. Univariate and multivariate analyses were conducted to evaluate the impact of preoperative APT on PICs. In addition, Kaplan-Meier method was used for survival analysis and the impact of PICs on patients' postoperative outcomes was evaluated. RESULTS A total of 216 patients were included in this study. There were 47 patients (21.76%) with preoperative APT; 169 patients (78.24%) without preoperative APT. The incidence of PICs in the APT group was significantly higher when compared with that in the nAPT group (36.17% vs. 20.71%, p = 0.028<0.05). Furthermore, significant differences were both observed in multivariate analysis (p = 0.035<0.05) and survival analysis (log rank χ2 = 5.415, p = 0.020<0.05). However, there was no significant difference between the outcomes of patients suffering from PICs and that of patients not suffering from PICs (p = 0.377 > 0.05). CONCLUSIONS In conclusion, preoperative APT may be a risk factor for PICs in ICH patients undergoing surgical treatment significantly.
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Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Chao Han
- Qingdao Central Hospital Group, Qingdao, P. R. China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
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Ullmann M, Guzman R, Mariani L, Soleman J. The effect of anti-thrombotics on the postoperative bleeding rate in patients undergoing craniotomy for brain tumor. Br J Neurosurg 2024; 38:798-804. [PMID: 34423703 DOI: 10.1080/02688697.2021.1968340] [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: 02/28/2021] [Revised: 06/15/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The peak prevalence of many brain tumors is in elderly patients. These patients are often treated with platelet inhibitors (PIs) or anticoagulants (ACs), creating a challenge for neurosurgeons concerning the perioperative management. The aim of this study is to analyze the effect of PI/AC treatment on the postoperative bleeding rates in patients undergoing craniotomy due to a brain tumor. METHODS Retrospective analysis of 415 consecutive patients undergoing craniotomy/craniectomy due to a brain tumor. Ninety-nine patients with PI/AC treatment (PI/AC group consisting of 64 PI, 29 AC, and six multiple) and 316 patients without PI/AC (control group) were primarily compared for hemorrhage rate. Secondary outcome measures were clinical outcome and mortality. The association between short preoperative discontinuation (≤5 days), early postoperative resumption time (≤5 days), as well as short total discontinuation time (≤5 days) of PI/AC and postoperative bleeding rates was analyzed. RESULTS Postoperative bleeding rates were comparable between the groups (12.2% and 13.5% in the PI/AC and control group, respectively; p=.74). The majority of bleeds were asymptomatic (85.2%). No significant difference in the postoperative mortality rate was observed (1.0% and 1.6% in the PI/AC and the control group, respectively; p=.67). Shorter discontinuation time of PI/AC was not significantly associated with higher postoperative bleeding rates (preoperative: 12.1% vs. 12.3%; p=.94, postoperative: 11.1% vs. 12.5%, respectively; p=.87, total: 16.7% vs. 12%, respectively; p=.73). CONCLUSIONS Patients treated with PI/AC undergoing craniotomy for the resection of brain tumor do not seem to have increased rates of postoperative bleeding or mortality. We did not find a significant correlation between short discontinuation time of PI/AC in the perioperative period and postoperative bleeding.
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Affiliation(s)
- Muriel Ullmann
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Luigi Mariani
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Jehuda Soleman
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
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Kapapa T, Jesuthasan S, Schiller F, Schiller F, Woischneck D, Gräve S, Barth E, Mayer B, Oehmichen M, Pala A. Outcome after decompressive craniectomy in older adults after traumatic brain injury. Front Med (Lausanne) 2024; 11:1422040. [PMID: 39040896 PMCID: PMC11260794 DOI: 10.3389/fmed.2024.1422040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024] Open
Abstract
Objective Globally, many societies are experiencing an increase in the number of older adults (>65 years). However, there has been a widening gap between the chronological and biological age of older adults which trend to a more active and social participating part of the society. Concurrently, the incidence of traumatic brain injury (TBI) is increasing globally. The aim of this study was to investigate the outcome after TBI and decompressive craniectomy (DC) in older adults compared with younger patients. Methods A retrospective, multi-centre, descriptive, observational study was conducted, including severe TBI patients who were treated with DC between 2005 and 2022. Outcome after discharge and 12 months was evaluated according to the Glasgow Outcome Scale (Sliding dichotomy based on three prognostic bands). Significance was established as p ≤ 0.05. Results A total of 223 patients were included. The majority (N = 158, 70.9%) survived TBI and DC at discharge. However, unfavourable outcome was predominant at discharge (88%) and after 12 months (67%). There was a difference in favour of younger patients (≤65 years) between the age groups at discharge (p = 0.006) and at 12 months (p < 0.001). A subgroup analysis of the older patients (66 to ≤74 vs. ≥75 years) did not reveal any significant differences. After 12 months, 64% of the older patients had a fatal outcome. Only 10% of those >65 years old had a good or very good outcome. 25% were depending on support in everyday activities. After 12 months, the age (OR 0.937, p = 0.007, CI 95%: 0.894-0.981; univariate) and performed cranioplasty (univariate and multivariate results) were influential factors for the dichotomized GOS. For unfavourable outcome after 12 months, the thresholds were calculated for age = 55.5 years (p < 0.001), time between trauma and surgery = 8.25 h (p = 0.671) and Glasgow Coma Scale (GCS) = 4 (p = 0.429). Conclusion Even under the current modern conditions of neuro-critical care, with significant advances in intensive care and rehabilitation medicine, the majority of patients >65 years of age following severe TBI and DC died or were dependent and usually required extensive support. This aspect should also be taken into account during decision making and counselling (inter-, intradisciplinary or with relatives) for a very mobile and active older section of society, together with the patient's will.
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Affiliation(s)
- Thomas Kapapa
- Neurosurgical Department, University Hospital Ulm, Ulm, Germany
| | | | | | | | | | - Stefanie Gräve
- Section Interdisciplinary Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Eberhard Barth
- Section Interdisciplinary Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | | | - Andrej Pala
- Neurosurgical Department, University Hospital Ulm, Ulm, Germany
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Kienzler JC, Fandino J. The Impact of Aspirin in Brain Tumor Surgery: To Stop or Not to Stop? Cureus 2023; 15:e51231. [PMID: 38283531 PMCID: PMC10821756 DOI: 10.7759/cureus.51231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Given the lack of guidelines regarding perioperative management of neurosurgical patients taking antiplatelet medication, a break of aspirin intake for elective brain surgery is recommended. To the best of our knowledge, only three clinical studies have been published comparing re-bleeding rates in patients undergoing elective brain surgery with and without aspirin. We present a case of an 81-year-old woman who was admitted for elective craniotomy and brain metastases resection. She presented with a right-sided hemianopsia for > two weeks and further investigation by magnetic resonance imaging (MRI) showed the left occipital lesion. For primary cardiovascular prevention, the patient was prescribed prophylactic low-dose aspirin 100 mg. A platelet function test on the day of admission detected highly pathological values. Surgery was scheduled the next day, and aspirin intake was paused. The platelet function test was repeated the morning before surgery. Interestingly, the test showed a 20% above-normal level platelet function. Craniotomy and tumor resection were performed in a routine fashion and no increased bleeding tendency was reported intraoperatively. Postoperatively, the right-sided hemianopsia was immediately regressive. MRI performed 24 hours after surgery demonstrated a complete tumor resection without any signs of rebleeding. The patient was discharged five days after surgery without any neurological deficits. The literature is limited and guidelines are missing on the topic of management of antiplatelet medication in elective brain surgery. As confirmed by the present case and a review of the literature, elective craniotomy and tumor resection under antiplatelet medication may be considered in certain cases with risk and benefit stratification. More data and randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
| | - Javier Fandino
- Department of Neurosurgery, Hirslanden Medical Center Aarau and Zurich, Aarau, CHE
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Wu Z, Wang H, Zhao J, Wang C, Liu H, Wang C, Li A, Hu J. Preoperative Fibrinogen Levels and Function as Predictive Factors for Acute Bleeding in the Hematoma Cavity After Burr Hole Drainage in Patients with CSDH. World Neurosurg 2023; 180:e364-e375. [PMID: 37769840 DOI: 10.1016/j.wneu.2023.09.072] [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: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Burr hole drainage (BHD) is the primary surgical intervention for managing chronic subdural hematoma (CSDH). However, it can lead to postoperative complications such as acute bleeding within the hematoma cavity and hematoma recurrence. The objective of this study is to identify the risk factors for these complications and develop a predictive model for acute hematoma cavity bleeding after BHD in patients with CSDH. METHODS This study presents a retrospective cohort investigation conducted at a single center. The clinical dataset of 308 CSDH patients who underwent BHD at a hospital from 2016 to 2022 was analyzed to develop and assess a prognostic model. RESULTS The nonbleeding group exhibited a significant correlation between fibrinogen (FIB) and thrombin time (TT), whereas no correlation was observed in the bleeding group. Notably, both FIB and TT were identified as risk factors for postoperative acute bleeding within the hematoma cavity. We developed a prognostic model to predict the occurrence of postoperative acute bleeding within the hematoma cavity after BHD in patients with CSDH. The model incorporated FIB, TT, coronary artery disease, and Glasgow Coma Scale scores. The model exhibited good discrimination (area under the curve: 0.725) and calibration (Hosmer-Leeshawn goodness of fit test: P > 0.1). Furthermore, decision curve analysis demonstrated the potential clinical benefit of implementing this prediction model. CONCLUSIONS The predictive model developed in this study can forecast the risk of postoperative acute bleeding within the hematoma cavity, thus aiding clinicians in selecting the optimal treatment approach for patients with CSDH.
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Affiliation(s)
- Zejun Wu
- Department of Neurosurgery, Taihe Hospital, Jinzhou Medical University Union Training Base, Shiyan, China; Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Hui Wang
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Junshuang Zhao
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chaobin Wang
- Department of Neurosurgery, Taihe Hospital, Jinzhou Medical University Union Training Base, Shiyan, China
| | - Haodong Liu
- The First Clinical College, Hubei University of Medicine, Shiyan, China
| | - Chaojia Wang
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Anrong Li
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Juntao Hu
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China; Hubei KeyLaboratory of Embryonic Stem Cell Research, Tai-He Hospital, Hubei University of Medicine, Shiyan, China.
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Bazzi R, Sharp V, Hecht J. Effect of Antiplatelet and Anticoagulant Agents on Outcomes Following Emergent Surgery for Traumatic Brain Injuries. Am Surg 2023; 89:5397-5406. [PMID: 36786276 DOI: 10.1177/00031348231157412] [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] [Indexed: 02/15/2023]
Abstract
PURPOSE Traumatic brain injury (TBI) is the largest cause of death from injury in the United States. This study utilized the Michigan Trauma Quality Improvement Program (MTQIP) database to determine the effect that antiplatelets and anticoagulants (AP/AC) have on outcomes following emergent surgery for TBI patients. BASIC PROCEDURES Patients were included with age ≥18 years, maximum head/neck abbreviated injury score (AIS) ≥2, and underwent a neurosurgical procedure within 24 hours. Patients were excluded if they had an AIS ≥3 in other body region or no signs of life at initial evaluation. MAIN FINDINGS Within the 1,932 patients analyzed, 139 (8.74%) were in the warfarin with or without (+/-) aspirin cohort, 101 (6.35%) in the direct oral anticoagulants (DOAC) +/- aspirin cohort, 169 (10.62%) in the clopidogrel +/- aspirin cohort, and 1,182 (74.29%) in the no AP/AC cohort (control group). After controlling for demographic and clinical characteristics, no significant difference in mortality rates was observed in the treatment groups (P > 0.05). However, our subgroup analysis did reveal a significantly higher mortality rate within the warfarin and aspirin subgroup when compared to the control group (odds ratio [OR], 2.368; confidence interval [CI], 1.306-4.294, P = 0.005). With regards to hospital complications, there was a significant increase in this outcome within the DOAC +/- aspirin (OR, 1.825; CI, 1.143-2.915, P = 0.012) and clopidogrel +/- aspirin (OR, 1.82; CI, 1.244-2.663, P=0.002) groups. CONCLUSION Patients on AP/AC who experience a TBI requiring an emergent operation do not have an increased risk of mortality compared to patients not on AP/AC.
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Affiliation(s)
- Rola Bazzi
- Inpatient Pharmacy, Trinity Health Ann Arbor, Ypsilant, MI, USA
| | - Victoria Sharp
- Department of Surgery, Trinity Health Ann Arbor, Ypsilant, MI, USA
| | - Jason Hecht
- Inpatient Pharmacy, Trinity Health Ann Arbor, Ypsilant, MI, USA
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Wagner A, Wostrack M, Hartz F, Heim J, Hameister E, Hildebrandt M, Meyer B, Winter C. The role of extended coagulation screening in adult cranial neurosurgery. BRAIN & SPINE 2023; 3:101756. [PMID: 37383462 PMCID: PMC10293229 DOI: 10.1016/j.bas.2023.101756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Abstract
Introduction Postoperative hemorrhage after adult cranial neurosurgery is a serious complication with substantial morbidity and mortality. Research question We investigated if an extended preoperative screening and an early treatment of previously undetected coagulopathies may decrease the risk of postoperative hemorrhage. Methods A prospective study cohort of patients undergoing elective cranial surgery and receiving the extended coagulatory work-up were compared to a propensity matched historical control cohort. The extended work-up included a standardized questionnaire on the patient's bleeding history as well as coagulatory tests of Factor XIII, von-Willebrand-Factor and PFA-100®. Deficiencies were substituted perioperatively. The primary outcome was determined as the surgical revision rate due to postoperative hemorrhage. Results The study cohort and the control cohort included 197 cases each, without any significant difference in the preoperative intake of anticoagulant medication (p = .546). Most common interventions were resections of malignant tumors (41%), benign tumors (27%) and neurovascular surgeries (9%) in both cohorts. Imaging revealed postoperative hemorrhage in 7 cases (3.6%) in the study cohort and 18 cases (9.1%) in the control cohort (p = .023). Of these, revision surgeries were significantly more common in the control cohort with 14 cases (9.1%) compared to 5 cases (2.5%) in the study cohort (p = .034). Differences in mean intraoperative blood loss were not significant with 528 ml in the study cohort and 486 ml in the control cohort (p = .376). Conclusion Preoperative extended coagulatory screening may allow for revealing previously undiagnosed coagulopathies with subsequent preoperative substitution and thereby reduction of risk for postoperative hemorrhage in adult cranial neurosurgery.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Frederik Hartz
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Johannes Heim
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Erik Hameister
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
| | - Martin Hildebrandt
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Christof Winter
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
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Khanafer A, Cimpoca A, Bhogal P, Babiy-Pachomow O, Kurucz P, Ganslandt O, Henkes H. Low incidence of hemorrhagic complications both during and after surgical procedures in patients maintained on prasugrel single antiplatelet therapy. J Neuroradiol 2023; 50:65-73. [PMID: 35306003 DOI: 10.1016/j.neurad.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/09/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Prasugrel (Pra) is a third-generation thienopyridine that inhibits platelet aggregation via irreversible blockade of P2Y12 receptors. While several published studies have examined the use of Pra and acetylsalicylic acid (ASA) in coronary and neurovascular stenting procedures, there is only anecdotal evidence regarding the use of Pra as single antiplatelet therapy (SAPT) in open surgical procedures. This topic has become important because previous studies have revealed that neurovascular devices with antithrombotic coatings can be implanted using non-invasive procedures in patients maintained on Pra SAPT. MATERIAL AND METHODS Patients who underwent open surgery under Pra SAPT between March 2020 and February 2022 were evaluated retrospectively. Adequate platelet inhibition both before and after the procedures was verified in all patients using Multiplate (Roche Diagnostics) and VerifyNow (Accriva) tests. Intraoperative and postoperative hemorrhagic events were recorded based on reviews of the procedure reports and interviews with the surgeons. RESULTS The study enrolled 21 patients who underwent 23 open surgical procedures while maintained on Pra SAPT. The procedures included one extirpation of a brain arteriovenous malformation, seven extra-intracranial bypass surgeries, four ventriculoperitoneal shunts, one eye enucleation for an intractable orbital infection, two gastrostomies, one bone flap reinsertion after craniectomy, one decompressive craniectomy, one case requiring cranial surgical wound care, one colporrhaphy, one transurethral resection of urinary bladder cancer, two tumor oophorectomy/hysterectomy procedures, and one aneurysm clipping. None of the 23 procedures resulted in excessive intraoperative or postoperative hemorrhage. CONCLUSION In a small retrospective series of patients who required antiplatelet therapy for neurovascular indications, Pra SAPT resulted in no significant increase in the incidence of perioperative and postoperative hemorrhagic complications.
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Affiliation(s)
- Ali Khanafer
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany.
| | | | - Paul Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | | | - Peter Kurucz
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Oliver Ganslandt
- Neurochirurgische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany; Medical Faculty, Universität Duisburg-Essen, Essen, Germany
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Muacevic A, Adler JR, Rei K, Andraos C, Reddy V, Brazdzionis J, Kashyap S, Siddiqi J. Incidence and Risk Factors for Superficial and Deep Vein Thrombosis in Post-Craniotomy/Craniectomy Neurosurgical Patients. Cureus 2022; 14:e32476. [PMID: 36644041 PMCID: PMC9835848 DOI: 10.7759/cureus.32476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Background Venous thromboembolism (VTE) is quite common among post-operative neurosurgical patients. This study aims to identify the incidence of deep vein thrombosis (DVT) and superficial vein thrombosis (SVT) among post-craniotomy/craniectomy patients and further evaluate established hypercoagulability risk factors such as trauma, tumors, and surgery. Methodology This single-center retrospective study investigated 197 patients who underwent a craniotomy/craniectomy. The incidences of DVT and SVT were compared, along with laterality and peripherally inserted central catheter (PICC) line involvement. A multivariate logistic regression analysis was conducted to identify risk factors for post-craniotomy/craniectomy VTE. This model included variables such as age, post-operative days before anticoagulant administration, female sex, indications for surgery such as tumor and trauma, presence of a PICC line, and anticoagulant administration. Results Among the 197 post-craniotomy/craniectomy patients (39.6% female; mean age 53.8±15.7 years), the incidences of DVT, SVT, and VTE were 4.6%, 9.6%, and 12.2%, respectively. The multivariate logistic regression analysis found that increasing the number of days between surgery and administration of anticoagulants significantly increased the risk of VTE incidence (odds ratio 1.183, 95% CI 1.068-1.311, p = 0.001). Conclusions Contrary to existing evidence, this study did not find trauma or the presence of tumors to be risk factors for VTE. Future prospective studies should assess VTE risk assessment models such as "3 Bucket" or "Caprini" to develop universal guidelines for administering anticoagulant therapy to post-craniotomy/craniectomy patients that consider the timing of post-operative therapy initiation.
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Krueger EM, DiGiorgio AM, Jagid J, Cordeiro JG, Farhat H. Current Trends in Mild Traumatic Brain Injury. Cureus 2021; 13:e18434. [PMID: 34737902 PMCID: PMC8559421 DOI: 10.7759/cureus.18434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 10/02/2021] [Indexed: 12/12/2022] Open
Abstract
In this review, we provide an overview of the current research and treatment of all types of traumatic brain injury (TBI) before illustrating the need for improved care specific to mild TBI patients. Contemporary issues pertaining to acute care of mild TBI including prognostication, neurosurgical intervention, repeat radiographic imaging, reversal of antiplatelet and anticoagulation medications, and cost savings initiatives are reviewed. Lastly, the effect of COVID-19 on TBI is addressed.
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Affiliation(s)
- Evan M Krueger
- Neurological Surgery, Carle Foundation Hospital, Urbana, USA
| | - Anthony M DiGiorgio
- Neurological Surgery, University of California San Francisco, San Francisco, USA
| | - Jonathan Jagid
- Neurological Surgery, University of Miami, Coral Gables, USA
| | | | - Hamad Farhat
- Neurological Surgery, Advocate Aurora Health Care, Downers Grove, USA
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Aspirin does not affect hematoma growth in severe spontaneous intracranial hematoma. Neurosurg Rev 2021; 45:1491-1499. [PMID: 34643829 DOI: 10.1007/s10143-021-01675-2] [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: 05/10/2021] [Revised: 08/20/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
Hematoma growth (HG) affects the prognosis of patients with spontaneous intracranial hematoma (ICH), but there is still a lack of evidence about the effects of aspirin (acetylsalicylic acid, ASA) on HG in patients with severe ICH. This study retrospectively analyzed patients with severe ICH who met the inclusion and exclusion criteria in Beijing Tiantan Hospital, Capital Medical University, between January 1, 2015, and July 31, 2019. Severe ICH patients were divided into ASA group and nASA groups according to ASA usage, and the incidence of HG between the groups was compared. Univariate analysis was performed by the Mann-Whitney U test, chi-square test, or Fisher exact test. Multivariate logistic regression analysis was used to analyze the impact of ASA on HG and to screen for risk factors of HG. In total, 221 patients with severe ICH were consecutively enrolled in this study. There were 72 (32.6%) patients in the ASA group and 149 patients in the nASA group. Although the incidence of HG in the nASA group was higher than that in the ASA group (34.9% VS 22.2%, p = 0.056), ASA did not significantly affect the occurrence of HG (p = 0.285) after adjusting for initial hematoma volume, high blood pressure at admission, coronary heart disease, and GCS at admission. In addition, we found that high blood pressure at admission was a risk factor for HG. Prior ASA does not increase the incidence of HG in severe ICH patients, and high blood pressure at admission is a risk factor for HG.
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12
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Yang J, Liu Q, Mo S, Wang K, Li M, Wu J, Jiang P, Yang S, Guo R, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. The Effect of Preoperative Antiplatelet Therapy on Early Postoperative Rehemorrhage and Outcomes in Patients With Spontaneous Intracranial Hematoma. Front Aging Neurosci 2021; 13:681998. [PMID: 34276341 PMCID: PMC8283695 DOI: 10.3389/fnagi.2021.681998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose The effect of antiplatelet therapy (APT) on early postoperative rehemorrhage and outcomes of patients with spontaneous intracerebral hemorrhage (ICH) is still unclear. This study is to evaluate the effect of preoperative APT on early postoperative rehemorrhage and outcomes in ICH patients. Methods This was a multicenter cohort study. ICH patients undergoing surgery were divided into APT group and no antiplatelet therapy (nAPT) group according to whether patients received APT or not. Chi-square test, t-test, and Mann–Whitney U test were used to compare the differences in variables, postoperative rehematoma, and outcomes between groups. Multivariate logistics regression analysis was used to correct for confounding variables, which were different in group comparison. Results One hundred fifty ICH patients undergoing surgical treatment were consecutively included in this study. Thirty five (23.33%) people were included in the APT group, while 115 (76.67%) people were included in the nAPT group. The incidence of early postoperative rehemorrhage in the APT group was significantly higher than that in the nAPT group (25.7% VS 10.4%, p = 0.047 < 0.05). After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT had no significant effect on early postoperative rehemorrhage (p = 0.067). There was no statistical difference between the two groups in early poorer outcomes (p = 0.222) at 14 days after surgery. After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT also had no significant effect on early poorer modified Rankin Scale (mRS) (p = 0.072). Conclusion In conclusion, preoperative APT appears to be safe and have no significant effect on early postoperative rehematoma and outcomes in ICH patients.
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Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Maogui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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13
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Ebel F, Ullmann M, Guzman R, Soleman J. Does the discontinuation time of antiplatelet or anticoagulation treatment affect hemorrhagic complications in patients undergoing craniotomy for neurovascular lesions? Br J Neurosurg 2021; 35:619-624. [PMID: 34030525 DOI: 10.1080/02688697.2021.1929835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The number of patients treated with platelet inhibitors (PI) and/or anticoagulants (AC) in neurosurgery is increasing. The aim of this study was to analyse the effect of PI/AC discontinuation time on hemorrhagic events after craniotomy for neurovascular pathologies. METHODS The 30-day postoperative bleeding rates were retrospectively compared between short (≤5 days) and long (>5 days) discontinuation time of PI/AC before and after surgery. Kaplan-Meier survival analysis comparing time to postoperative bleeding and the effect of PI/AC discontinuation time on bleeding rates were analysed. Potential risk factors for postoperative bleeding were further analysed in uni- and multivariate analysis. RESULTS Out of 215 consecutive patients undergoing craniotomy for neurovascular lesions between January 2009 and April 2019, 23.3% were treated with PI/AC. Of these 36% (n = 18) and 20.8% (n = 10) were included in the short pre- and postoperative discontinuation group, respectively. Bleeding rates were comparable between the pre- and postoperative short and long discontinuation groups (preoperative 11.1% vs 10%, p = .659; postoperative 0% vs 13.2%, p = .566). In-hospital mortality rates and time to bleed of the groups were comparable as well. Similarly, the rate for thromboembolic events was not significantly affected by the pre- or postoperative discontinuation time of PI/AC. After multivariate analysis preoperative bleeding of the lesion was significantly associated with postoperative bleeding. CONCLUSIONS Patients with short discontinuation time of PI/AC treatment undergoing craniotomy for the treatment of neurovascular lesions do not appear to have increased rates of postoperative bleeding.
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Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Muriel Ullmann
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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14
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Kinnunen J, Satopää J, Niemelä M, Putaala J. Coagulopathy and its effect on treatment and mortality in patients with traumatic intracranial hemorrhage. Acta Neurochir (Wien) 2021; 163:1391-1401. [PMID: 33759013 PMCID: PMC8053656 DOI: 10.1007/s00701-021-04808-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/10/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role of coagulopathy in patients with traumatic brain injury has remained elusive. In the present study, we aim to assess the prevalence of coagulopathy in patients with traumatic intracranial hemorrhage, their clinical features, and the effect of coagulopathy on treatment and mortality. METHODS An observational, retrospective single-center cohort of consecutive patients with traumatic intracranial hemorrhage treated at Helsinki University Hospital between 01 January and 31 December 2010. We compared clinical and radiological parameters in patients with and without coagulopathy defined as drug- or disease-induced, i.e., antiplatelet or anticoagulant medication at a therapeutic dose, thrombocytopenia (platelet count < 100 E9/L), international normalized ratio > 1.2, or thromboplastin time < 60%. Primary outcome was 30-day all-cause mortality. Logistic regression analysis allowed to assess for factors associated with coagulopathy and mortality. RESULTS Of our 505 patients (median age 61 years, 65.5% male), 206 (40.8%) had coagulopathy. Compared to non-coagulopathy patients, coagulopathy patients had larger hemorrhage volumes (mean 140.0 mL vs. 98.4 mL, p < 0.001) and higher 30-day mortality (18.9% vs. 9.7%, p = 0.003). In multivariable analysis, older age, lower admission Glasgow Coma Scale score, larger hemorrhage volume, and conservative treatment were independently associated with mortality. Surgical treatment was associated with lower mortality in both patients with and without coagulopathy. CONCLUSIONS Coagulopathy was more frequent in patients with traumatic intracranial hemorrhage presenting larger hemorrhage volumes compared to non-coagulopathy patients but was not independently associated with higher 30-day mortality. Hematoma evacuation, in turn, was associated with lower mortality irrespective of coagulopathy.
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Affiliation(s)
- Janne Kinnunen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Jarno Satopää
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, 00260, Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland
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15
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Savioli G, Ceresa IF, Luzzi S, Giotta Lucifero A, Pioli Di Marco MS, Manzoni F, Preda L, Ricevuti G, Bressan MA. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? MEDICINA (KAUNAS, LITHUANIA) 2021; 57:357. [PMID: 33917141 PMCID: PMC8067857 DOI: 10.3390/medicina57040357] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022]
Abstract
Background and objectives: In patients who receive antiplatelet therapy (APT), the bleeding risk profile after mild head trauma (MHT) still needs clarification. Some studies have demonstrated an association with bleeding risk, whereas others have not. We studied the population of our level II emergency department (ED) trauma center to determine the risk of bleeding in patients receiving APT and whether bleeding results not from antiplatelet agents but rather from age. We assessed the bleeding risk, the incidence of intracranial hemorrhage (ICH) that necessitated hospitalization for observation, the need for cranial neurosurgery, the severity of the patient's condition at discharge, and the frequency of ED revisits for head trauma in patients receiving APT. Materials and Methods: This retrospective single-center study included 483 patients receiving APT who were in the ED for MHT in 2019. The control group consisted of 1443 patients in the ED with MHT over the same period who were not receiving APT or anticoagulant therapy. Our ED diagnostic therapeutic protocol mandates both triage and the medical examination to identify patients with MHT who are taking any anticoagulant or APT. Results: APT was not significantly associated with bleeding risk (p > 0.05); as a risk factor, age was significantly associated with the risk of bleeding, even after adjustment for therapy. Patients receiving APT had a greater need of surgery (1.2% vs. 0.4%; p < 0.0001) and a higher rate of hospitalization (52.9% vs. 37.4%; p < 0.0001), and their clinical condition was more severe (evaluated according to the exit code value on a one-dimensional quantitative five-point numerical scale) at the time of discharge (p = 0.013). The frequency of ED revisits due to head trauma did not differ between the two groups. Conclusions: The risk of bleeding in patients receiving APT who had MHT was no higher than that in the control group. However, the clinical condition of patients receiving APT, including hospital admission for ICH monitoring and cranial neurosurgical interventions, was more severe.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (M.S.P.D.M.); (M.A.B.)
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Iride Francesca Ceresa
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (M.S.P.D.M.); (M.A.B.)
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.)
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.)
| | - Maria Serena Pioli Di Marco
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (M.S.P.D.M.); (M.A.B.)
| | - Federica Manzoni
- Health Promotion—Environmental Epidemiology Unit, Hygiene and Health Prevention Department, Health Protection Agency, 27100 Pavia, Italy;
| | - Lorenzo Preda
- Radiology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, 27100 Pavia, Italy;
- Saint Camillus International University of Health Sciences, 00152 Rome, Italy
| | - Maria Antonietta Bressan
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (M.S.P.D.M.); (M.A.B.)
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16
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King B, Milling T, Gajewski B, Costantini TW, Wick J, Price MA, Mudaranthakam D, Stein DM, Connolly S, Valadka A, Warach S. Restarting and timing of oral anticoagulation after traumatic intracranial hemorrhage: a review and summary of ongoing and planned prospective randomized clinical trials. Trauma Surg Acute Care Open 2020; 5:e000605. [PMID: 33313417 PMCID: PMC7716676 DOI: 10.1136/tsaco-2020-000605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/27/2022] Open
Abstract
Anticoagulant-associated traumatic intracranial hemorrhage (tICrH) is a devastating injury with high morbidity and mortality. For survivors, treating clinicians face the dilemma of restarting oral anticoagulation with scarce evidence to guide them. Thromboembolic risk is high from the bleeding event, patients’ high baseline risks, that is, the pre-existing indication for anticoagulation, and the risk of immobility after the bleeding episode. This must be balanced with potentially devastating hematoma expansion or new hemorrhagic lesions. Retrospective evidence and expert opinion support restarting oral anticoagulants in most patients with tICrH, but timing is uncertain. Researchers have failed to make clear distinctions between tICrH and spontaneous intracranial hemorrhage (sICrH), which have differing natural histories. While both appear to benefit from restarting, sICrH has a higher rebleeding risk and similar or lower thrombotic risk. Clinical equipoise on restarting is also divergent. In sICrH, equipoise is centered on whether to restart. In tICrH, it is centered on when. Several prospective randomized clinical trials are ongoing or about to start to examine the risk–benefit of restarting. Most of them are restricted to patients with sICrH, with antiplatelet control groups. Most are also restricted to direct oral anticoagulants (DOACs), as they are associated with a lower overall risk of ICrH. There is some overlap with tICrH via subdural hematoma, and one trial is specific to restart timing with DOACs in only traumatic cases. This is a narrative review of the current evidence for restarting anticoagulation and restart timing after tICrH along with a summary of the ongoing and planned clinical trials.
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Affiliation(s)
- Ben King
- College of Medicine, Department of Health Systems and Population Health Sciences, University of Houston, Houston, Texas, USA
| | - Truman Milling
- Seton Dell Medical School Stroke Institute, Ascension Seton, Austin, Texas, USA
| | - Byron Gajewski
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego Health, San Diego, California, USA
| | - Jo Wick
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Dinesh Mudaranthakam
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Deborah M Stein
- Department of Surgery, University of California-San Francisco, School of Medicine, San Francisco, California, USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Steven Warach
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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17
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Lee H, Tan C, Tran V, Mathew J, Fitzgerald M, Leong R, Kambourakis T, Gantner D, Udy A, Hunn M, Rosenfeld JV, Tee J. The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma. J Neurotrauma 2020; 37:2499-2506. [DOI: 10.1089/neu.2019.6943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Hui Lee
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
| | - Caleb Tan
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
| | - Vanessa Tran
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
| | - Joseph Mathew
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Trauma Services, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Trauma Services, Alfred Health, Melbourne, Victoria, Australia
| | - Ronald Leong
- Aged Care Services, Alfred Health, Melbourne, Victoria, Australia
| | | | - Dashiell Gantner
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Martin Hunn
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jin Tee
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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18
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Soleman J, Ullmann M, Greuter L, Ebel F, Guzman R. Mortality and Outcome in Elderly Patients Undergoing Emergent or Elective Cranial Surgery. World Neurosurg 2020; 146:e575-e589. [PMID: 33130138 DOI: 10.1016/j.wneu.2020.10.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Due to the aging population, the number of elderly patients in need of cranial surgery for various neurosurgical pathologies is growing. We sought to compare mortality and outcome of elderly patients undergoing cranial surgery with a younger population. METHODS This was a retrospective analysis of adult patients undergoing craniotomy or craniectomy for various indications. Patients were allocated to 4 age groups (<65 years, 65-74 years, 75-84 years, ≥85 years; groups 1-4, respectively). Primary outcome was 30-day mortality rate, whereas secondary outcome measurements were clinical outcome measured by the modified Rankin Scale score, morbidity (bleeding, infection, and thromboembolic complications), length of stay (LOS), and discharge location. RESULTS We included 838 consecutive patients. Overall, 30-day mortality was 5.0% (n = 42), showing significant difference between the groups (2.8%, 7.3%, 7.5%, and 22.7% groups 1-4, respectively; P < 0.001). Mortality remained statistically significantly different between the groups also after stratification for elective or emergent surgery. Cumulative 30-day mortality-free rate was significantly different between the groups as well (log rank test χ2 = 24.58, P < 0.001). Elderly patients showed significantly greater rates of bleeding (P = 0.003), longer LOS (P < 0.001), more discharges to rehabilitation facilities (P = 0.008), and a trend toward worst modified Rankin Scale score at follow-up (P = 0.08). After multivariate regression analysis, age (≥75 years) and lower preoperative Glasgow Coma Scale score (<14) were significantly associated with greater mortality rates, whereas postoperative thrombosis prophylaxis was a protective factor for mortality. CONCLUSIONS In patients undergoing craniotomy or craniectomy, advanced age seems to be associated with greater mortality and bleeding rates, longer LOS, and more discharge to rehabilitation facilities.
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Affiliation(s)
- Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Muriel Ullmann
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland
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19
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Trevisi G, Sturiale CL, Scerrati A, Rustemi O, Ricciardi L, Raneri F, Tomatis A, Piazza A, Auricchio AM, Stifano V, Romano C, De Bonis P, Mangiola A. Acute subdural hematoma in the elderly: outcome analysis in a retrospective multicentric series of 213 patients. Neurosurg Focus 2020; 49:E21. [DOI: 10.3171/2020.7.focus20437] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe objective of this study was to analyze the risk factors associated with the outcome of acute subdural hematoma (ASDH) in elderly patients treated either surgically or nonsurgically.METHODSThe authors performed a retrospective multicentric analysis of clinical and radiological data on patients aged ≥ 70 years who had been consecutively admitted to the neurosurgical department of 5 Italian hospitals for the management of posttraumatic ASDH in a 3-year period. Outcome was measured according to the Glasgow Outcome Scale (GOS) at discharge and at 6 months’ follow-up. A GOS score of 1–3 was defined as a poor outcome and a GOS score of 4–5 as a good outcome. Univariate and multivariate statistics were used to determine outcome predictors in the entire study population and in the surgical group.RESULTSOverall, 213 patients were admitted during the 3-year study period. Outcome was poor in 135 (63%) patients, as 65 (31%) died during their admission, 33 (15%) were in a vegetative state, and 37 (17%) had severe disability at discharge. Surgical patients had worse clinical and radiological findings on arrival or during their admission than the patients undergoing conservative treatment. Surgery was performed in 147 (69%) patients, and 114 (78%) of them had a poor outcome. In stratifying patients by their Glasgow Coma Scale (GCS) score, the authors found that surgery reduced mortality but not the frequency of a poor outcome in the patients with a moderate to severe GCS score. The GCS score and midline shift were the most significant predictors of outcome. Antiplatelet drugs were associated with better outcomes; however, patients taking such medications had a better GCS score and better radiological findings, which could have influenced the former finding. Patients with fixed pupils never had a good outcome. Age and Charlson Comorbidity Index were not associated with outcome.CONCLUSIONSTraumatic ASDH in the elderly is a severe condition, with the GCS score and midline shift the stronger outcome predictors, while age per se and comorbidities were not associated with outcome. Antithrombotic drugs do not seem to negatively influence pretreatment status or posttreatment outcome. Surgery was performed in patients with a worse clinical and radiological status, reducing the rate of death but not the frequency of a poor outcome.
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Affiliation(s)
| | - Carmelo Lucio Sturiale
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Alba Scerrati
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
- 4Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Oriela Rustemi
- 5UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza
| | - Luca Ricciardi
- 6UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza-Roma; and
| | - Fabio Raneri
- 5UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza
| | | | - Amedeo Piazza
- 6UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza-Roma; and
| | - Anna Maria Auricchio
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Vito Stifano
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Carmine Romano
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
| | - Pasquale De Bonis
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
- 4Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Annunziato Mangiola
- 1Neurosurgical Unit, Ospedale Santo Spirito, Pescara
- 7Department of Neurosciences, Imaging and Clinical Sciences, “G. D’Annunzio” University, Chieti, Italy
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