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Acta Neurochirurgica

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Open Access 05-10-2023 | Low Molecular Weight Heparin | Review Article

Thromboembolic prophylaxis in neurosurgical practice: a systematic review

Authors: Zhaoyuan Zhang, Husule Cai, Carmen L. A. Vleggeert-Lankamp

Published in: Acta Neurochirurgica | Issue 11/2023

Abstract

Background

In neurosurgical patients, the risk of developing venous thromboembolism (VTE) is high due to the relatively long duration of surgical interventions, usually long immobilization time after surgery, and possible neurological deficits which can negatively influence mobility. In neurosurgical clinical practice, there is lack of consensus on optimal prophylaxis against VTE, mechanical or pharmacological.

Objective

To systematically review available literature on the incidence of VTE in neurosurgical interventions and to establish an optimum prevention strategy.

Methods

A literature search was performed in PubMed, Embase, Web of Science, Cochrane Library, and EmCare, based on a sensitive search string combination. Studies were selected by predefined selection criteria, and risk of bias was assessed by Newcastle–Ottawa Quality Assessment Scale and Cochrane risk of bias.

Results

Twenty-five studies were included, half of which had low risk of bias (21 case series, 3 comparative studies, 1 RCT). VTE was substantially higher if the evaluation was done by duplex ultrasound (DUS), or another systematic screening method, in comparison to clinical evaluation (clin). Without prophylaxis DVT, incidence varied from 4 (clin) to 10% (DUS), studies providing low molecular weight heparin (LMWH) reported an incidence of 2 (clin) to 31% (DUS), providing LMWH and compression stockings (CS) reported an incidence of 6.4% (clin) to 29.8% (DUS), and providing LMWH and intermittent pneumatic compression devices (IPC) reported an incidence of 3 (clin) to 22.3% (DUS). Due to a lack of data, VTE incidence could not meaningfully be compared between patients with intracranial and spine surgery. The reported incidence of pulmonary embolism (PE) was 0 to 7.9%.

Conclusion

Low molecular weight heparin, compression stockings, and intermittent pneumatic compression devices were all evaluated to give reduction in VTE, but data were too widely varying to establish an optimum prevention strategy. Systematic screening for DVT reveals much higher incidence percentages in comparison to screening solely on clinical grounds and is recommended in follow-up of neurosurgical procedures with an increased risk for DVT development in order to prevent occurrence of PE.

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Agarwal N, Zenonos GA, Agarwal P, Walch FJ, Roach E, Stokes SJ, Friedlander RM, Gerszten PC (2019) Risk-to-benefit ratio of venous thromboembolism prophylaxis for neurosurgical procedures at a quaternary referral center. Neurosurgery 84:355–361. https://doi.org/10.1093/neuros/nyy035CrossRefPubMed

Al-Dujaili TM, Majer CN, Madhoun TE, Kassis SZ, Saleh AA (2012) Deep venous thrombosis in spine surgery patients: incidence and hematoma formation. Int Surg 97(2):150–154. https://doi.org/10.9738/CC71.1CrossRefPubMedPubMedCentral

Ali NES, Alyono JC, Song Y, Kouhi A, Blevins NH (2021) Postoperative venous thromboembolism after neurotologic surgery. J Neurol Surg Part B: Skull Base 82(3):378–382. https://doi.org/10.1055/s-0039-3400223CrossRef

Caine GJ, Stonelake PS, Lip GY, Kehoe ST (2002) The hypercoagulable state of malignancy: pathogenesis and current debate. Neoplasia 4:465–473. https://doi.org/10.1038/sj.neo.7900263CrossRefPubMedPubMedCentral

Caprini JA (2005) Thrombosis risk assessment as a guide to quality patient care. Dis Mon 51:70–78. https://doi.org/10.1016/j.disamonth.2005.02.003CrossRefPubMed

Carrabba G, Riva M, Conte V, Di Cristofori A, Caroli M, Locatelli M, Castellani M, Bucciarelli P, Artoni A, Stocchetti N, Martinelli I, Rampini P (2018) Risk of post-operative venous thromboembolism in patients with meningioma. J Neurooncol 138:401–406. https://doi.org/10.1007/s11060-018-2810-zCrossRefPubMed

Chaichana KL, Pendleton C, Jackson C, Martinez-Gutierrez JC, Diaz-Stransky A, Aguayo J, Olivi A, Weingart J, Gallia G, Lim M, Brem H, Quinones-Hinojosa A (2013) Deep venous thrombosis and pulmonary embolisms in adult patients undergoing craniotomy for brain tumors. Neurol Res 35:206–211. https://doi.org/10.1179/1743132812y.0000000126CrossRefPubMed

Chibbaro S, Cebula H, Todeschi J, Fricia M, Vigouroux D, Abid H, Kourbanhoussen H, Pop R, Nannavecchia B, Gubian A, Prisco L, Ligarotti GKI, Proust F, Ganau M (2018) Evolution of prophylaxis protocols for venous thromboembolism in neurosurgery: results from a prospective comparative study on low-molecular-weight heparin, elastic stockings, and intermittent pneumatic compression devices. World Neurosurg 109:e510–e516. https://doi.org/10.1016/j.wneu.2017.10.012CrossRefPubMed

Cloney MB, Goergen J, Hopkins BS, Dhillon ES, Dahdaleh NS (2018) Factors associated with venous thromboembolic events following ICU admission in patients undergoing spinal surgery: an analysis of 1269 consecutive patients. J Neurosurg Spine 30:99–105. https://doi.org/10.3171/2018.5.Spine171027CrossRefPubMed

10.

Daley MJ, Ali S, Brown CV (2015) Late venous thromboembolism prophylaxis after craniotomy in acute traumatic brain injury. Am Surg 81:207–211CrossRefPubMed

11.

Dermody M, Alessi-Chinetti J, Iafrati MD, Estes JM (2011) The utility of screening for deep venous thrombosis in asymptomatic, non-ambulatory neurosurgical patients. J Vasc Surg 53:1309–1315. https://doi.org/10.1016/j.jvs.2010.10.115CrossRefPubMed

12.

Dhillon ES, Khanna R, Cloney M, Roberts H, Cybulski GR, Koski TR, Smith ZA, Dahdaleh NS (2017) Timing and risks of chemoprophylaxis after spinal surgery: a single-center experience with 6869 consecutive patients. J Neurosurg Spine 27:681–693. https://doi.org/10.3171/2017.3.Spine161076CrossRefPubMed

13.

Ebeling M, Lüdemann W, Frisius J, Karst M, Schedel I, Gerganov V, Samii A, Fahlbusch R (2018) Venous thromboembolic complications with and without intermittent intraoperative and postoperative pneumatic compression in patients with glioblastoma multiforme using intraoperative magnetic resonance imaging. A retrospective study Neurochirurgie 64:161–165. https://doi.org/10.1016/j.neuchi.2018.04.007CrossRefPubMed

14.

Eisenring CV, Neidert MC, SabanésBové D, Held L, Sarnthein J, Krayenbühl N (2013) Reduction of thromboembolic events in meningioma surgery: a cohort study of 724 consecutive patients. PLoS One 8:e79170. https://doi.org/10.1371/journal.pone.0079170CrossRefPubMedPubMedCentral

15.

Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW (2008) Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest 133:381s-453s. https://doi.org/10.1378/chest.08-0656

16.

Guo F, Shashikiran T, Chen X, Yang L, Liu X, Song L (2015) Clinical features and risk factor analysis for lower extremity deep venous thrombosis in Chinese neurosurgical patients. J Neurosci Rural Pract 6:471–476. https://doi.org/10.4103/0976-3147.169801CrossRefPubMedPubMedCentral

17.

Hamilton MG, Hull RD, Pineo GF (1994) Venous thromboembolism in neurosurgery and neurology patients: a review. Neurosurgery 34:280–296; discussion 296. https://doi.org/10.1227/00006123-199402000-00012

18.

Hoefnagel D, Kwee LE, Van Putten EHP, Kros JM, Dirven CMF, Dammers R (2014) The incidence of postoperative thromboembolic complications following surgical resection of intracranial meningioma. A retrospective study of a large single center patient cohort. Clin Neurol Neurosurg 123:150–154. https://doi.org/10.1016/j.clineuro.2014.06.001CrossRefPubMed

19.

Ikeda T, Miyamoto H, Hashimoto K, Akagi M (2017) Predictable factors of deep venous thrombosis in patients undergoing spine surgery. J Orthop Sci 22:197–200. https://doi.org/10.1016/j.jos.2016.11.014CrossRefPubMed

20.

Kaewborisutsakul A, Tunthanathip T, Yuwakosol P, Inkate S, Pattharachayakul S (2020) Incidence and risk factors for venous thromboembolism following craniotomy for intracranial tumors: a cohort study. Asian J Neurosurg 15:31–38. https://doi.org/10.4103/ajns.AJNS_351_19CrossRefPubMedPubMedCentral

21.

Karsy M, Azab MA, Harper J, Abou-Al-Shaar H, Guan J, Eli I, Brock AA, Ormond RD, Hosokawa PW, Gouripeddi R, Butcher R, Cole CD, Menacho ST, Couldwell WT (2020) Evaluation of a D-dimer protocol for detection of venous thromboembolism. World Neurosurgery 133:E774–E783. https://doi.org/10.1016/j.wneu.2019.09.160CrossRefPubMed

22.

Kearon C (2003) Natural history of venous thromboembolism. Circulation 107:I22-30. https://doi.org/10.1161/01.Cir.0000078464.82671.78CrossRefPubMed

23.

Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR (2012) Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:e419S-e496S. https://doi.org/10.1378/chest.11-2301CrossRefPubMedPubMedCentral

24.

Kimmell KT, Jahromi BS (2015) Clinical factors associated with venous thromboembolism risk in patients undergoing craniotomy. J Neurosurg 122:1004–1011. https://doi.org/10.3171/2014.10.Jns14632CrossRefPubMed

25.

Li J, Ren X, Zhu X, Chen H, Lin Z, Huang M, Gu Z (2020) Clinical predictive factors of lower extremity deep vein thrombosis in relative high-risk patients after neurosurgery: a retrospective study. Dis Markers 2020:5820749. https://doi.org/10.1155/2020/5820749CrossRefPubMedPubMedCentral

26.

Lukassen J, Groen J, Jacobs W, Vleggeert-Lankamp C (2015) Thromboembolic prophylaxis in neurosurgical practice: a review. J Spine 4:2CrossRef

27.

Mammen EF (1992) Pathogenesis of venous thrombosis. Chest 102:640s–644s. https://doi.org/10.1378/chest.102.6_supplement.640sCrossRefPubMed

28.

Masuda EM, Kistner RL (2010) The case for managing calf vein thrombi with duplex surveillance and selective anticoagulation. Dis Mon 56:601–613. https://doi.org/10.1016/j.disamonth.2010.06.011CrossRefPubMed

29.

Moser KM, LeMoine JR (1981) Is embolic risk conditioned by location of deep venous thrombosis? Ann Intern Med 94:439–444. https://doi.org/10.7326/0003-4819-94-4-439CrossRefPubMed

30.

Nakano F, Matsubara T, Ishigaki T, Hatazaki S, Mouri G, Nakatsuka Y, Suzuki H (2018) Incidence and risk factor of deep venous thrombosis in patients undergoing craniotomy for brain tumors: a Japanese single-center, retrospective study. Thromb Res 165:95–100. https://doi.org/10.1016/j.thromres.2018.03.016CrossRefPubMed

31.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj 372:n71. https://doi.org/10.1136/bmj.n71CrossRefPubMedPubMedCentral

32.

Palareti G, Cosmi B, Lessiani G, Rodorigo G, Guazzaloca G, Brusi C, Valdré L, Conti E, Sartori M, Legnani C (2010) Evolution of untreated calf deep-vein thrombosis in high risk symptomatic outpatients: the blind, prospective CALTHRO study. Thromb Haemost 104:1063–1070. https://doi.org/10.1160/th10-06-0351CrossRefPubMed

33.

Park JH, Lee KE, Yu YM, Park YH, Choi SA (2019) Incidence and risk factors for venous thromboembolism after spine surgery in Korean patients. World Neurosurg 128:e289–e307. https://doi.org/10.1016/j.wneu.2019.04.140CrossRefPubMed

34.

Patel AP, Koltz MT, Sansur CA, Gulati M, Hamilton DK (2013) An analysis of deep vein thrombosis in 1277 consecutive neurosurgical patients undergoing routine weekly ultrasonography. J Neurosurg 118:505–509. https://doi.org/10.3171/2012.11.Jns121243CrossRefPubMed

35.

Prell J, Schenk G, Taute BM, Scheller C, Marquart C, Strauss C, Rampp S (2018) Reduced risk of venous thromboembolism with the use of intermittent pneumatic compression after craniotomy: a randomized controlled prospective study. J Neurosurg:1–7. https://doi.org/10.3171/2017.9.Jns17533

36.

Rethinasamy R, Alias A, Kandasamy R, Raffiq A, Looi MC, Hillda T (2019) Deep vein thrombosis and the neurosurgical patient. Malaysian J Med Sci 26(5):139–147. https://doi.org/10.21315/mjms2019.26.5.13CrossRef

37.

Righini M, Paris S, Le Gal G, Laroche JP, Perrier A, Bounameaux H (2006) Clinical relevance of distal deep vein thrombosis. Rev Lit Data Thromb Haemost 95:56–64CrossRef

38.

Rinaldo L, Brown DA, Bhargav AG, Rusheen AE, Naylor RM, Gilder HE, Monie DD, Youssef SJ, Parney IF (2019) Venous thromboembolic events in patients undergoing craniotomy for tumor resection: incidence, predictors, and review of literature. J Neurosurg 132:10–21. https://doi.org/10.3171/2018.7.Jns181175CrossRefPubMed

39.

Rolston JD, Han SJ, Bloch O, Parsa AT (2014) What clinical factors predict the incidence of deep venous thrombosis and pulmonary embolism in neurosurgical patients? J Neurosurg 121:908–918. https://doi.org/10.3171/2014.6.Jns131419CrossRefPubMed

40.

Samuel S, Patel N, McGuire MF, Salazar M, Nguyen T (2019) Analysis of venous thromboembolism in neurosurgical patients undergoing standard versus routine ultrasonography. J Thromb Thrombolysis 47:209–215. https://doi.org/10.1007/s11239-018-1761-8CrossRefPubMed

41.

Shi S, Cheng J, Chen H, Zhang Y, Zhao Y, Wang B (2020) Preoperative and intraoperative predictors of deep venous thrombosis in adult patients undergoing craniotomy for brain tumors: a Chinese single-center, retrospective study. Thromb Res 196:245–250. https://doi.org/10.1016/j.thromres.2020.09.005CrossRefPubMed

42.

Sjåvik K, Bartek J Jr, Solheim O, Ingebrigtsen T, Gulati S, Sagberg LM, Förander P, Jakola AS (2016) Venous thromboembolism prophylaxis in meningioma surgery: a population-based comparative effectiveness study of routine mechanical prophylaxis with or without preoperative low-molecular-weight heparin. World Neurosurg 88:320–326. https://doi.org/10.1016/j.wneu.2015.12.077CrossRefPubMed

43.

Smith TR, Lall RR, Graham RB, McClendon J Jr, Lall RR, Nanney AD, Adel JG, Zakarija A, Chandler JP (2014) Venous thromboembolism in high grade glioma among surgical patients: results from a single center over a 10 year period. J Neurooncol 120:347–352. https://doi.org/10.1007/s11060-014-1557-4CrossRefPubMed

44.

Stecker M, Michel K, Antaky K, Cherian S, Koyfmann F (2014) Risk factors for DVT/PE in patients with stroke and intracranial hemorrhage. Open Neurol J 8:1–6. https://doi.org/10.2174/1874205x01408010001CrossRefPubMedPubMedCentral

45.

Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK (2021) Antithrombotic therapy for VTE disease: second update of the CHEST Guideline and Expert Panel Report. Chest 160:e545–e608. https://doi.org/10.1016/j.chest.2021.07.055CrossRefPubMed

46.

Wells G SB, O’Connell D, Peterson J, Welch V, Losos M, Tugwell P (2013) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses.

47.

Yun R, Sciubba DM, Lewin JJ 3rd, Streiff MB, Haut ER, Lau BD, Shermock KM, Kraus PS, Popoola VO, Dalpoas SE (2020) Defects in processes of care for pharmacologic prophylaxis are common among neurosurgery patients who develop in-hospital postoperative venous thromboembolism. World Neurosurg 134:e664–e671. https://doi.org/10.1016/j.wneu.2019.10.163CrossRefPubMed

Title: Thromboembolic prophylaxis in neurosurgical practice: a systematic review
Authors: Zhaoyuan Zhang
Husule Cai
Carmen L. A. Vleggeert-Lankamp
Publication date: 05-10-2023
Publisher: Springer Vienna
Keywords: Low Molecular Weight Heparin
Phlebothrombosis
Spinal Surgery
Published in: Acta Neurochirurgica / Issue 11/2023
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI: https://doi.org/10.1007/s00701-023-05792-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Thromboembolic prophylaxis in neurosurgical practice: a systematic review

Abstract

Background

Objective

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Objective

Methods

Results

Conclusion

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