J Neurol Surg B Skull Base 2020; 81(S 01): S1-S272
DOI: 10.1055/s-0040-1702367
Oral Presentations
Georg Thieme Verlag KG Stuttgart · New York

Anticoagulation for Cerebral Venous Sinus Thrombosis after Posterior Fossa Schwannoma Surgery: Worth the Risk?

Christina Jackson
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
,
Pavan Shah
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
,
Laura Saleh
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
,
Gary Gallia
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
,
Chetan Bettegowda
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
,
Jon Weingart
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
,
Henry Brem
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
,
Rafael Tamargo
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
,
Michael Lim
1   Johns Hopkins School of Medicine, Baltimore, Maryland, United States
› Author Affiliations
Further Information

Publication History

Publication Date:
05 February 2020 (online)

 

Background: Cerebral venous sinus thrombosis (CVST) is a rare complication after posterior fossa schwannoma surgeries. Previous reports on the development and management of postoperative CVST after posterior fossa schwannoma surgery are limited to case reports or by small sample sizes. Moreover, there is limited evidence that therapeutic anticoagulation (tAC) improves outcomes in this patient population. Therefore, we sought to characterize the risk of postoperative CVST in the largest series to date, and to compare post-thrombosis symptoms and radiographic improvement in patients who were treated with tAC and those who were not.

Methods: We conducted a retrospective review of patients who underwent resection for posterior fossa schwannomas at a tertiary care center between 2009 and 2019. MRIs were routinely obtained within 48-hours postoperatively, 3-months postoperatively, or as clinically indicated. We defined CTSV as radiographic evidence of filling defects within the sinus ([Fig. 1]). We compared clinical, radiographic, and intraoperative characteristics between patients who developed postoperative CVST and those who did not. We used logistic regression to identify risk factors associated with the development of postoperative CVST. Among patients who developed postoperative CVST, we further compared post-thrombosis symptoms, radiographic improvement, and bleeding complications between patients who received tAC and those who did not.

Results: We identified 646 patients who underwent resection for posterior fossa schwannomas, of which 44 (6.8%) patients developed postoperative CVST. There were no significant differences in clinical, radiographic, and intraoperative characteristics between patients who developed postoperative CVST and those who did not (Table 1). For example, mean tumor size (2.16 vs. 2.28 cm, p = 0.48), mean operating time (9.9 versus. 9.5 hours, p = 0.21), surgical fluid balance (2.2L vs. 1.9, p = 0.14), and surgical approach (81.8% retrosigmoid vs. 88.2%, p = 0.13) were similar between groups. Among patients who developed postoperative CVST, 21 (47.7%) patients had medical risk factors for thrombosis (e.g. smoking, malignancies), and 37 (84.1%) patients were asymptomatic (Table 2). Patients who received tAC (n = 9) were largely similar to patients who did not (n = 35), with the exception that median time to diagnosis was significantly longer in those who received tAC (median 11 vs. 2 days, p < 0.001). Despite this, there were no significant differences in thrombosis-related complications and radiographic improvement of thrombosis at 6 months between the two groups. However, one patient (11.1%) who received tAC developed a clinically significant bleeding complication (epidural hematoma), which required a prolonged ICU stay.

Conclusion: In the largest series of CVST after posterior fossa schwannoma resection to date, postoperative CVST remains an uncommon complication (6.8%). However, we did not identify any predictors of postoperative CVST, making the identification of high-risk patients challenging. Nevertheless, we found that patients who did not receive tAC did not have lower rates of radiographic resolution of CVST nor were they more symptomatic from the CVST. In light of collateral drainage from the contralateral sinus system, the risk of clinically significant bleeding complications with tAC in the immediate postoperative setting, and the equivalent outcomes between patients who received tAC and those who did not, avoidance of tAC may be a reasonable management strategy for these patients.

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