Therapeutic Anticoagulation After Craniotomies: Is the Risk for Secondary Hemorrhage Overestimated?

Abstract

Objective Deep venous thrombosis (DVT) and pulmonary embolism (PE) are major causes of postoperative morbidity and mortality in surgery. However, there is neither a standardized protocol for perioperative prevention of DVT or PE in neurosurgery nor a consensus concerning the management of postoperative DVT or PE after craniotomy in the early postoperative course.

Methods We retrospectively analyzed management and complications in a group of patients with postoperative DVT or PE after craniotomy between 2006 and 2011 to estimate the risk of secondary hemorrhage under therapeutic anticoagulation. The interval between time of craniotomy and diagnosis of PE or DVT, administered anticoagulation, and the appearance of a clinically relevant secondary hemorrhage were analyzed.

Results Forty-two patients met the given criteria. Indications for surgery were intracranial tumors (n = 33), aneurysms (n = 5), and hematomas (n = 4). PE or DVT was observed between the first and the 28th postoperative day (median, fifth postoperative day). Therapeutic anticoagulation was performed with enoxaparin or heparin (according to partial thromboplastin time levels). Full heparinization was applied in 30 patients between the second and the 30th postoperative day (median, 12th postoperative day). None of these patients developed a secondary hemorrhage.

Conclusion The documented differences in the anticoagulative drug used, the drug's dosage, and the start of medication reflect the lack of a standardized protocol concerning the treatment of postoperative PE or DVT after craniotomy. A more aggressive management regarding the application of anticoagulative drugs after craniotomy may be justified considering the absence of clinically relevant hemorrhages in this study and the life-threatening potential of perioperative DVT or PE.

Keywords

craniotomy - therapeutic anticoagulation - pulmonary embolism - deep venous thrombosis

• References

• 1 Hamilton MG, Hull RD, Pineo GF. Venous thromboembolism in neurosurgery and neurology patients: a review. Neurosurgery 1994; 34 (2) 280-296 , discussion 296
• 2 Macdonald RL, Amidei C, Baron J , et al. Randomized, pilot study of intermittent pneumatic compression devices plus dalteparin versus intermittent pneumatic compression devices plus heparin for prevention of venous thromboembolism in patients undergoing craniotomy. Surg Neurol 2003; 59 (5) 363-372 , discussion 372–374
• 3 Black PM, Baker MF, Snook CP. Experience with external pneumatic calf compression in neurology and neurosurgery. Neurosurgery 1986; 18 (4) 440-444
• 4 Inci S, Erbengi A, Berker M. Pulmonary embolism in neurosurgical patients. Surg Neurol 1995; 43 (2) 123-128 , discussion 128–129
• 5 Barnett HG, Clifford JR, Llewellyn RC. Safety of mini-dose heparin administration for neurosurgical patients. J Neurosurg 1977; 47 (1) 27-30
• 6 Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med 1988; 318 (18) 1162-1173
• 7 Kakkar VV, Stringer MD. Prophylaxis of venous thromboembolism. World J Surg 1990; 14 (5) 670-678
• 8 Oster G, Tuden RL, Colditz GA. A cost-effectiveness analysis of prophylaxis against deep-vein thrombosis in major orthopedic surgery. JAMA 1987; 257 (2) 203-208
• 9 Salzman EW, Davies GC. Prophylaxis of venous thromboembolism: analysis of cost effectiveness. Ann Surg 1980; 191 (2) 207-218
• 10 Wen DY, Hall WA. Complications of subcutaneous low-dose heparin therapy in neurosurgical patients. Surg Neurol 1998; 50 (6) 521-525
• 11 Turpie AGG, Gallus AS, Beattie WS, Hirsh J. Prevention of venous thrombosis in patients with intracranial disease by intermittent pneumatic compression of the calf. Neurology 1977; 27 (5) 435-438
• 12 Rachinger JC, Koman G, Scheller C, Prell J, Rampp S, Strauss C. Practice in the perioperative prevention of deep vein thrombosis in German neurosurgical departments: is there a trend towards homogenization?. Cent Eur Neurosurg 2011; 72 (3) 115-119
• 13 Apuzzo MLJ. Brain Surgery. Complication Avoidance and Management. New York: Churchill Livingstone; 1993
• 14 Kleindienst A, Harvey HB, Mater E , et al. Early antithrombotic prophylaxis with low molecular weight heparin in neurosurgery. Acta Neurochir (Wien) 2003; 145 (12) 1085-1090 , discussion 1090–1091
• 15 Norwood SH, McAuley CE, Berne JD , et al. Prospective evaluation of the safety of enoxaparin prophylaxis for venous thromboembolism in patients with intracranial hemorrhagic injuries. Arch Surg 2002; 137 (6) 696-701 , discussion 701–702
• 16 Raabe A, Gerlach R, Zimmermann M, Seifert V. The risk of haemorrhage associated with early postoperative heparin administration after intracranial surgery. Acta Neurochir (Wien) 2001; 143 (1) 1-7
• 17 Dickinson LD, Miller LD, Patel CP, Gupta SK. Enoxaparin increases the incidence of postoperative intracranial hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in patients with brain tumors. Neurosurgery 1998; 43 (5) 1074-1081
• 18 Constantini S, Kanner A, Friedman A , et al. Safety of perioperative minidose heparin in patients undergoing brain tumor surgery: a prospective, randomized, double-blind study. J Neurosurg 2001; 94 (6) 918-921
• 19 Nurmohamed MT, van Riel AM, Henkens CMA , et al. Low molecular weight heparin and compression stockings in the prevention of venous thromboembolism in neurosurgery. Thromb Haemost 1996; 75 (2) 233-238
• 20 Agnelli G, Piovella F, Buoncristiani P , et al. Enoxaparin plus compression stockings compared with compression stockings alone in the prevention of venous thromboembolism after elective neurosurgery. N Engl J Med 1998; 339 (2) 80-85
• 21 Cerrato D, Ariano C, Fiacchino F. Deep vein thrombosis and low-dose heparin prophylaxis in neurosurgical patients. J Neurosurg 1978; 49 (3) 378-381
• 22 Goldhaber SZ, Dunn K, Gerhard-Herman M, Park JK, Black PM. Low rate of venous thromboembolism after craniotomy for brain tumor using multimodality prophylaxis. Chest 2002; 122 (6) 1933-1937
• 23 Cuker A, Cines D. How I treat heparin-induced thrombocytopenia (HIT). Blood 2012; 199 (10) 2209-2218
• 24 Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood 2005; 106 (8) 2710-2715
• 25 Swann KW, Black PM, Baker MF. Management of symptomatic deep venous thrombosis and pulmonary embolism on a neurosurgical service. J Neurosurg 1986; 64 (4) 563-567
• 26 Ruff RL, Posner JB. Incidence and treatment of peripheral venous thrombosis in patients with glioma. Ann Neurol 1983; 13 (3) 334-336
• 27 Gerlach R, Scheuer T, Beck J, Woszczyk A, Seifert V, Raabe A. Risk of postoperative hemorrhage after intracranial surgery after early nadroparin administration: results of a prospective study. Neurosurgery 2003; 53 (5) 1028-1034 , discussion 1034–1035
• 28 Epstein NE. A review of the risks and benefits of differing prophylaxis regimens for the treatment of deep venous thrombosis and pulmonary embolism in neurosurgery. Surg Neurol 2005; 64 (4) 295-301 , discussion 302