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Wilhelmy F, Gaier M, Planitzer U, Kasper J, Prasse G, Frydrychowicz C, Oesemann R, Meixensberger J, Lindner D. Venous thromboembolism and intracranial hemorrhage in patients undergoing glioblastoma surgery. Sci Rep 2023; 13:21679. [PMID: 38066037 PMCID: PMC10709630 DOI: 10.1038/s41598-023-48542-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
In the perioperative management of patients with glioblastoma (GBM), physicians face the question of whether and when to administer prophylactic or therapeutic anticoagulation (AC). In this study, we investigate the effects of the timing of postoperative heparinization on thromboembolic events (TE) and postoperative hemorrhage (bleeding, PH) as well as the interactions between the two in the context of an underlying intracerebral malignancy. For this retrospective data analysis, 222 patients who underwent surgery for grade IV glioblastoma, IDH-wildtype (2016 CNS WHO) between 01/01/2014 and 31/12/2019 were included. We followed up for 12 months. We assessed various biographical and clinical data for risk factors and focused on the connection between timepoint of AC and adverse events. Subgroup analyses were performed for pulmonary artery embolism (PE), deep vein thrombosis, and postoperative intracranial hemorrhage (PH) that either required surgical intervention or was controlled radiologically only. Statistical analysis was performed using Mann-Whitney U-Test, Chi-square test, Fisher's exact test and univariate binomial logistic regression. p values below 0.05 were considered statistically significant. There was no significant association between prophylactic AC within 24 h and more frequent major bleeding (p = 0.350). AC in patients who developed major bleeding was regularly postponed by the physician/surgeon upon detection of the re-bleeding; therefore, patients with PH were anticoagulated significantly later (p = 0.034). The timing of anticoagulant administration did not differ significantly between patients who experienced a thromboembolic event and those who did not (p = 0.634). There was considerable overlap between the groups. Three of the six patients (50%) with PE had to be lysed or therapeutically anticoagulated and thereafter developed major bleeding (p < 0.001). Patients who experienced TE were more likely to die during hospitalization than those with major bleeding (p = 0.022 vs. p = 1.00). Prophylactic AC within 24 h after surgery does not result in more frequent bleeding. Our data suggests that postoperative intracranial hemorrhage is not caused by prophylactic AC but rather is a surgical complication or the result of antithrombotic therapy. However, thromboembolic events worsen patient outcomes far more than postoperative bleeding. The fact that bleeding may occur as a complication of life-saving lysis therapy in the setting of a thromboembolic event should be included in this cost-benefit consideration.
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Affiliation(s)
- Florian Wilhelmy
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Michael Gaier
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Uwe Planitzer
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Johannes Kasper
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Gordian Prasse
- Division of Neuroradiology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Clara Frydrychowicz
- Division of Neuropathology, University Hospital Leipzig, Liebigstrasse 26, 04103, Leipzig, Germany
| | - René Oesemann
- Department of Anesthesiology and Intensive Care, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Jürgen Meixensberger
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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Chen D, Luo J, Zhang C, Tang L, Deng H, Chang T, Xu H, He M, Wan D, Zhang F, Wu M, Qian M, Zhou W, Yin G, Wang W, Dong L, Tang Z. Venous Thrombus Embolism in Polytrauma: Special Attention to Patients with Traumatic Brain Injury. J Clin Med 2023; 12:1716. [PMID: 36902502 PMCID: PMC10003329 DOI: 10.3390/jcm12051716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/06/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023] Open
Abstract
Venous thrombus embolism (VTE) is common after polytrauma, both of which are considered significant contributors to poor outcomes and mortality. Traumatic brain injury (TBI) is recognized as an independent risk factor for VTE and one of the most common components of polytraumatic injuries. Few studies have assessed the impact of TBI on the development of VTE in polytrauma patients. This study sought to determine whether TBI further increases the risk for VTE in polytrauma patients. A retrospective, multi-center trial was performed from May 2020 to December 2021. The occurrence of venous thrombosis and pulmonary embolism from injury to 28 days after injury was observed. Of 847 enrolled patients, 220 (26%) developed DVT. The incidence of DVT was 31.9% (122/383) in patients with polytrauma with TBI (PT + TBI group), 22.0% (54/246) in patients with polytrauma without TBI (PT group), and 20.2% (44/218) in patients with isolated TBI (TBI group). Despite similar Glasgow Coma Scale scores, the incidence of DVT in the PT + TBI group was significantly higher than in the TBI group (31.9% vs. 20.2%, p < 0.01). Similarly, despite no difference in Injury Severity Scores between the PT + TBI and PT groups, the DVT rate was significantly higher in the PT + TBI group than in the PT group (31.9% vs. 22.0%, p < 0.01). Delayed anticoagulant therapy, delayed mechanical prophylaxis, older age, and higher D-dimer levels were independent predictive risk factors for DVT occurrence in the PT + TBI group. The incidence of PE within the whole population was 6.9% (59/847). Most patients with PE were in the PT + TBI group (64.4%, 38/59), and the PE rate was significantly higher in the PT + TBI group compared to the PT (p < 0.01) or TBI (p < 0.05) group. In conclusion, this study characterizes polytrauma patients at high risk for VTE occurrence and emphasizes that TBI markedly increases the incidence of DVT and PE in polytrauma patients. Delayed anticoagulant therapy and delayed mechanical prophylaxis were identified as the major risk factors for a higher incidence of VTE in polytrauma patients with TBI.
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Affiliation(s)
- Deng Chen
- Department of Trauma Surgery, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jialiu Luo
- Department of Trauma Surgery, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Cong Zhang
- Department of Trauma Surgery, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Liangsheng Tang
- Department of Trauma Surgery, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Hai Deng
- Department of Trauma Surgery, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Teding Chang
- Department of Trauma Surgery, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Huaqiang Xu
- Intensive Care Unit, Trauma Center, Suizhou Central Hospital, Hubei University of Medicine, Suizhou 441300, China
| | - Miaobo He
- Intensive Care Unit, Trauma Center, Suizhou Central Hospital, Hubei University of Medicine, Suizhou 441300, China
| | - Dongli Wan
- Intensive Care Unit, Trauma Center, Suizhou Central Hospital, Hubei University of Medicine, Suizhou 441300, China
| | - Feiyu Zhang
- Department of Trauma Surgery, Trauma Center, Tianmen First People’s Hospital, Hubei University of Science and Technology, Tianmen 417300, China
| | - Mengfan Wu
- Department of Trauma Surgery, Trauma Center, Tianmen First People’s Hospital, Hubei University of Science and Technology, Tianmen 417300, China
| | - Min Qian
- Department of Emergency Medicine, The People’s Hospital of China Three Gorges University, China Three Gorges University, Yichang 443000, China
| | - Wen Zhou
- Department of Emergency Medicine, The People’s Hospital of China Three Gorges University, China Three Gorges University, Yichang 443000, China
| | - Gang Yin
- Department of Trauma Surgery, Trauma Center, Tianmen First People’s Hospital, Hubei University of Science and Technology, Tianmen 417300, China
| | - Wenguo Wang
- Intensive Care Unit, Trauma Center, Suizhou Central Hospital, Hubei University of Medicine, Suizhou 441300, China
| | - Liming Dong
- Department of Trauma Surgery, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zhaohui Tang
- Department of Trauma Surgery, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Shaftel KA, Cole TS, Jubran JH, Schriber TD, Little AS. Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 1-Craniotomy. Neurosurgery 2022; 91:247-255. [PMID: 35551171 DOI: 10.1227/neu.0000000000002001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/01/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite patients experiencing high recurrence and readmission rates after surgical management of nontraumatic subdural hematomas (SDHs), few studies have examined the causes and predictors of unplanned readmissions in this population on a national scale. OBJECTIVE To analyze independent factors predicting 30-day hospital readmissions after surgical treatment of nontraumatic SDH in patients who survived their index surgery and evaluate hospital readmission rates and charges. METHODS Using the Nationwide Readmissions Database, we identified patients who underwent craniotomy for nontraumatic SDH evacuation (2010-2015) using a retrospective cohort observational study design. National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables. RESULTS Among 49 013 patients, 10 643 (21.7%) had at least 1 readmission within 30 days of their index treatment and 38 370 (78.3%) were not readmitted. Annual readmission rates did not change during the study period ( P = .74). The most common primary causes of 30-day readmissions were recurrent SDH (n = 3949, 37.1%), venous thromboembolism (n = 1373, 12.9%), and delayed hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (n = 1363, 12.8%). Comorbidities that independently predicted readmission included congestive heart failure, chronic obstructive pulmonary disease, coagulopathy, diabetes mellitus, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disease, psychosis, and renal failure ( P ≤ .03). Household income in the 51st to 75th percentile was associated with a decreased risk of readmission. CONCLUSION National trends in 30-day readmission rates after nontraumatic SDH treatment by craniotomy provide quality benchmarks that can be used to drive quality improvement efforts on a national level.
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Affiliation(s)
- Kelly A Shaftel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Abunimer AM, Lak AM, Calvachi P, Smith TR, Aglio LS, Almefty KK, Dunn IF, Bi WL, Goldhaber SZ, Al-Mefty O. Early Detection and Management of Venous Thrombosis in Skull Base Surgery: Role of Routine Doppler Ultrasound Monitoring. Neurosurgery 2022; 91:115-122. [PMID: 35383697 DOI: 10.1227/neu.0000000000001936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), encompassing deep venous thrombosis (DVT) and pulmonary embolism (PE), causes postoperative morbidity and mortality in neurosurgical patients. The use of pharmacological prophylaxis for DVT prevention in the immediate postoperative period carries increased risk of intracranial hemorrhage, especially after skull base surgeries. OBJECTIVE To investigate the impact of routine Doppler ultrasound monitoring in prevention and tiered management of VTE after skull base surgery. METHODS We retrospectively analyzed a large cohort of consecutive adult patients who were prospectively and uniformly managed with routine monitoring by Doppler ultrasound for DVT after resection of a skull base tumor. RESULTS A total of 389 patients who underwent 459 surgeries for intracranial tumor resection were analyzed. Skull base meningioma was the most common pathology. Forty-four (9.59%) postoperative VTEs were detected: 9 (1.96%) with PE with or without DVT and 35 (7.63%) with DVT alone. Four cases of subsegmental PE were diagnosed without evidence of lower extremity DVT, possibly in the setting of peripherally inserted central catheters maintenance. One patient had a preoperative proximal DVT and underwent a prophylactic inferior vena cava filter but expired from PE after discharge. Prior history of VTE (risk ratio [RR] 5.13; 95% CI 2.76-7.18; P < .01), anesthesia duration (RR 1.14; 95% CI 1.03-1.27; P = .02), and blood transfusion (RR 1.95; 95% CI 1.01-3.37; P = .04) were associated with VTE development on multivariate analysis. CONCLUSION Routine postoperative venous ultrasound monitoring detects asymptomatic DVT guiding management. This is an alternative strategy to prescribing pharmacological VTE prophylaxis immediately after lengthy surgeries for intracranial tumors. Peripherally inserted central catheters were associated with subsegmental PE.
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Affiliation(s)
- Abdullah M Abunimer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Asad M Lak
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paola Calvachi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Linda S Aglio
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kaith K Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Park S, Kalfas S, Fazio TN, Neto AS, Macisaac C, Read DJ, Drummond KJ, Bellomo R. Venous thromboembolism prophylaxis and related outcomes in patients with traumatic brain injury and prolonged intensive care unit stay. CRIT CARE RESUSC 2021; 23:364-373. [PMID: 38046690 PMCID: PMC10692541 DOI: 10.51893/2021.4.oa1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Traumatic brain injury (TBI) patients with prolonged intensive care unit (ICU) stay are at risk of secondary intracranial haemorrhage (ICH) and venous thromboembolism (VTE). We aimed to study VTE prophylaxis, secondary ICH, and VTE prevalence and outcomes in this population. Design: Retrospective observational study. Setting: Level 1 trauma centre ICU. Patients: One hundred TBI patients receiving prolonged ICU treatment (≥ 7 days). Interventions: We collected data from medical records, pathology and radiology systems, and hospital and ICU admission databases. We analysed patient characteristics, interventions, episodes and types of secondary ICH and VTE, and timing and dosage of VTE prophylaxis. Results: Data from the 100 patients in our study showed that early use of compression stockings and pneumatic calf compression was common (75% and 91% in the first 3 days, respectively). VTE chemoprophylaxis, however, was only used in 14% of patients by Day 3 and > 50% by Day 10. We observed VTE in 12 patients (10 as pulmonary embolism), essentially all after Day 6. Radiologically confirmed secondary ICH occurred in 43% of patients despite normal coagulation. However, 72% of ICH events (42/58) were radiologically mild, and the median time of onset of ICH was Day 1, when only 3% of patients were on chemical prophylaxis. Moreover, 82% of secondary ICH events (48/58) occurred in the first 3 days, with no severe ICH thereafter. Conclusions: In TBI patients receiving prolonged ICU treatment, early chemical VTE prophylaxis was uncommon. Early secondary ICH was common and mostly radiologically mild, whereas later secondary ICH was essentially absent. In contrast, early VTE was essentially absent, whereas later VTE was relatively common. Earlier chemical VTE prophylaxis and/or ultrasound screening in this population appears logical.
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Affiliation(s)
- Seunga Park
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Stefanie Kalfas
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Timothy N. Fazio
- Health Intelligence Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Melbourne Medical School, Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Christopher Macisaac
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - David J. Read
- Trauma Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Katharine J. Drummond
- Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Surgery, Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
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Qian C, Huhtakangas J, Juvela S, Bode MK, Tatlisumak T, Savolainen M, Numminen H, Ollikainen J, Luostarinen L, Kupila L, Tetri S. Early vs. late enoxaparin for the prevention of venous thromboembolism in patients with ICH: A double blind placebo controlled multicenter study. Clin Neurol Neurosurg 2021; 202:106534. [PMID: 33578226 DOI: 10.1016/j.clineuro.2021.106534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/15/2021] [Accepted: 01/24/2021] [Indexed: 11/30/2022]
Abstract
BACKROUND Venous thromboembolism (VTE) after primary intracerebral hemorrhage (ICH) worsens patient prognosis. Administering low-molecular weight heparins (LMWH) to prevent VTE early (24 h) may increase the risk of hematoma enlargement, whereas administering late (72 h) after onset may decrease its effect on VTE prevention. The authors investigated when it is safe and effective to start LMWH in ICH patients. METHODS In the setting of double blinded, placebo controlled randomization, patients >18 years of age with paretic lower extremity, and admitted to the emergency room within 12 h of the onset of ICH, were randomized into two groups. Patients in the enoxaparin group received 20 mg twice a day 24 h (early) after the onset of ICH and in the placebo group 72 h (late) after onset respectively. Both groups immediately received intermittent pneumatic compression stockings at the ER. Patients were prospectively and routinely screened for VTE and hemorrhagic complications 1 day after entering the study and again before discharge. RESULTS 139 patients were included for randomization in this study. Only 3 patients developed VTE, 2 in the early enoxaparin group and one in the late enoxaparin group. No patients developed PE. Thromboembolic events (p = 0.901), risk of hematoma enlargement (p = 0.927) and overall outcome (P = 0.904) did not differ significantly between the groups. CONCLUSION Administering 40 mg/d LMWH for prevention of VTE to a spontaneous ICH patient is safe regardless of whether it is started 24 h (early) or 72 h (late) after the hemorrhage. Risk of hemorrhage enlargement is not associated with early LMWH treatment. Administering LMWH late did not increase VTEs.
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Affiliation(s)
- C Qian
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland
| | - J Huhtakangas
- Department of Neurology, Oulu University Hospital, Oulu, Finland
| | - S Juvela
- Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - M K Bode
- Department of Radiology, Oulu University Hospital, Oulu, Finland
| | - T Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - M Savolainen
- Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland; Department of Neurology, South Karelian Central Hospital, Lappeenranta, Finland
| | - H Numminen
- Department of Neurology, Tampere University Hospital, Finland
| | - J Ollikainen
- Department of Neurology, Tampere University Hospital, Finland
| | - L Luostarinen
- Department of Neurology, Päijät-Häme Central Hospital, Finland
| | - L Kupila
- Department of Neurology, Päijät-Häme Central Hospital, Finland
| | - S Tetri
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland.
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Kananeh MF, Fonseca-Paricio MJ, Liang JW, Sullivan LT, Sharma K, Shah SO, Vibbert MD. Ultra-Early Venous Thromboembolism (VTE) Prophylaxis in Spontaneous Intracerebral Hemorrhage (sICH). J Stroke Cerebrovasc Dis 2020; 30:105476. [PMID: 33253987 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To determine if ultra-early (<24 h) venous thromboembolism (VTE) prophylaxis was associated with hematoma growth in spontaneous intracerebral hemorrhage (ICH). BACKGROUND Patients with ICH have a high risk of VTE. Pharmacological prophylaxis such as unfractionated heparin (UFH) have been demonstrated to reduce VTE. However, published datasets exclude patients with recent ICH out of concern for hematoma enlargement. American Heart/Stroke Association guidelines recommend UFH 1-4 days after hematoma stabilization while the European Stroke Organization has no recommendations on when to begin UFH. Our institutional practice is to obtain stability CT scans at 6 to 24 h and to begin UFH following documented clinical and radiologic stability. We examined the impact of this practice on hematoma expansion. METHODS We performed a retrospective cohort analysis of consecutive ICH patients treated at a single tertiary academic referral center in the US. Demographic and clinical characteristics were abstracted. ICH volume was measured via 3D volumetrics for a CT head done on admission, follow-up stability, and prior to discharge. The primary outcome was analyzed as ≥3 mL hematoma enlargement. Secondary outcomes include hematoma expansion of ≥6mL and ≥ 33%, length of stay (LOS), discharge disposition and mortality. RESULTS A total of 163 ICH patients were analyzed. There were 58 (35.6%) patients in the ultra-early UFH group and UFH was initiated on average at 13.8 h from initial scan. There were 105 (64.6%) patients in the standard group who initiated UFH at an average of 46.6 h. The primary outcome of hematoma enlargement ≥3 mL was observed in 2/58(3.4%) patients with ultra-early initiation of UFH and in 7/105(6.7%) in the standard group (p=0.49). Secondary outcomes were not significant including hematoma expansion in the ultra-early group ≥ 6 mL 3/58 (5.2%) and ≥33% 7/58 (12.1%) (p=0.91, 0.61, respectively) as well as mortality or LOS. CONCLUSION Venous thromboembolism prophylaxis started ultra-early (≤24 h) after ICH was not associated with hematoma expansion.
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Affiliation(s)
- Mohammed F Kananeh
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
| | | | - John W Liang
- Mount Sinai Heath System, Department of Neurosurgery & Neurology, New York, New York, USA
| | - Lindsay T Sullivan
- Novant Health Forsyth Medical Center, Department of Neurology, Winston-Salem, North Carolina, USA
| | - Kumud Sharma
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
| | - Syed Omar Shah
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA.
| | - Matthew D Vibbert
- Thomas Jefferson University, Department of Neurosurgery, Philadelphia, Pennsylvania, USA
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Paciaroni M, Agnelli G, Alberti A, Becattini C, Guercini F, Martini G, Tassi R, Marotta G, Venti M, Acciarresi M, Mosconi MG, Marcheselli S, Fratticci L, D'Amore C, Ageno W, Versino M, De Lodovici ML, Carimati F, Pezzini A, Padovani A, Corea F, Scoditti U, Denti L, Tassinari T, Silvestrelli G, Ciccone A, Caso V. PREvention of VENous Thromboembolism in Hemorrhagic Stroke Patients - PREVENTIHS Study: A Randomized Controlled Trial and a Systematic Review and Meta-Analysis. Eur Neurol 2020; 83:566-575. [PMID: 33190135 DOI: 10.1159/000511574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/05/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In this randomized trial, currently utilized standard treatments were compared with enoxaparin for the prevention of venous thromboembolism (VTE) in patients with intracerebral hemorrhage (ICH). METHODS Enoxaparin (0.4 mg daily for 10 days) was started after 72 h from the onset of ICH. The primary outcome was symptomatic or asymptomatic deep venous thrombosis as assessed by ultrasound at the end of study treatment. The safety of enoxaparin was also assessed. We included the results of this study in a meta-analysis of all relevant studies comparing anticoagulants with standard treatments or placebo. RESULTS PREVENTIHS was prematurely stopped after the randomization of 73 patients, due to the low recruitment rate. The prevalence of any VTE at 10 days was 15.8% in the enoxaparin group and 20.0% in the control group (RR 0.79 [95% CI 0.29-2.12]); 2.6% of enoxaparin and 8.6% of standard therapy patients had severe bleedings (RR 0.31 [95% CI 0.03-2.82]). When these results were meta-analyzed with the results of the selected studies (4,609 patients; 194 from randomized trials), anticoagulants were associated with a nonsignificant reduction in any VTE (OR 0.81; 95% CI 0.43-1.51), in pulmonary embolism (OR 0.53; 95% CI, 0.17-1.60), and in mortality (OR 0.85; 95% CI 0.64-1.12) without increase in hematoma enlargement (OR 0.97; 95% CI, 0.31-3.04). CONCLUSIONS In patients with acute ICH, the use of anticoagulants to prevent VTE was safe but the overall level of evidence was low due to the low number of patients included in randomized clinical trials.
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Affiliation(s)
- Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy,
| | - Giancarlo Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Francesco Guercini
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | | | | | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Monica Acciarresi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Maria Giulia Mosconi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Lara Fratticci
- Humanitas Clinical and Research Center - IRCSS, Milano, Italy
| | - Cataldo D'Amore
- Stroke Unit, Ospedale di Portogruaro, Portogruaro (Venice), Italy
| | - Walter Ageno
- Department of Medicine, University of Insubria, Ospedale di Circolo, Varese, Italy
| | - Maurizio Versino
- Neurology and Stroke Unit, ASST Settelaghi, DMC University of Insubria, Varese, Italy
| | | | | | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Brescia, Italy
| | - Francesco Corea
- UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno, Italy
| | - Umberto Scoditti
- Stroke Unit, Neuroscience Department, University of Parma, Parma, Italy
| | - Licia Denti
- Stroke Unit - Dipartimento Geriatrico Riabilitativo - University of Parma, Parma, Italy
| | - Tiziana Tassinari
- Stroke Unit & Department of Neurology, Santa Corona Hospital, Pietra Ligure, Italy
| | | | - Alfonso Ciccone
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
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9
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Wilhelmy F, Hantsche A, Wende T, Kasper J, Reuschel V, Frydrychowicz C, Rasche S, Lindner D, Meixensberger J. Perioperative anticoagulation in patients with intracranial meningioma: No increased risk of intracranial hemorrhage? PLoS One 2020; 15:e0238387. [PMID: 32870937 PMCID: PMC7462284 DOI: 10.1371/journal.pone.0238387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Anticoagulation (AC) is a critical topic in perioperative and post-bleeding management. Nevertheless, there is a lack of data about the safe, judicious use of prophylactic and therapeutic anticoagulation with regard to risk factors and the cause and modality of brain tissue damage as well as unfavorable outcomes such as postoperative hemorrhage (PH) and thromboembolic events (TE) in neurosurgical patients. We therefore present retrospective data on perioperative anticoagulation in meningioma surgery. METHODS Data of 286 patients undergoing meningioma surgery between 2006 and 2018 were analyzed. We followed up on anticoagulation management, doses and time points of first application, laboratory values, and adverse events such as PH and TE. Pre-existing medication and hemostatic conditions were evaluated. The time course of patients was measured as overall survival, readmission within 30 days after surgery, as well as Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS). Statistical analysis was performed using multivariate regression. RESULTS We carried out AC with Fraxiparin and, starting in 2015, Tinzaparin in weight-adapted recommended prophylactic doses. Delayed (216 ± 228h) AC was associated with a significantly increased rate of TE (p = 0.026). Early (29 ± 21.9h) prophylactic AC, on the other hand, did not increase the risk of PH. We identified additional risk factors for PH, such as blood pressure maxima, steroid treatment, and increased white blood cell count. Patients' outcome was affected more adversely by TE than PH (+3 points in modified Rankin Scale in TE vs. +1 point in PH, p = 0.001). CONCLUSION Early prophylactic AC is not associated with an increased rate of PH. The risks of TE seem to outweigh those of PH. Early postoperative prophylactic AC in patients undergoing intracranial meningioma resection should be considered.
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Affiliation(s)
- Florian Wilhelmy
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Annika Hantsche
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Tim Wende
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Johannes Kasper
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | - Vera Reuschel
- Division of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Stefan Rasche
- Department of Anesthesiology and Intensive Care, University Hospital Leipzig, Leipzig, Germany
| | - Dirk Lindner
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
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10
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Cheang MY, Yeo TT, Chou N, Lwin S, Ng ZX. Is anticoagulation for venous thromboembolism safe for Asian elective neurosurgical patients? A single centre study. ANZ J Surg 2019; 89:919-924. [DOI: 10.1111/ans.15337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Mun Yoong Cheang
- Department of NeurosurgeryNational University Hospital Singapore
| | - Tseng Tsai Yeo
- Department of NeurosurgeryNational University Hospital Singapore
| | - Ning Chou
- Department of NeurosurgeryNational University Hospital Singapore
| | - Sein Lwin
- Department of NeurosurgeryNational University Hospital Singapore
| | - Zhi Xu Ng
- Department of NeurosurgeryNational University Hospital Singapore
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11
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Early Chemical Thromboprophylaxis Does not Increase the Risk of Intracranial Hematoma Progression in Patients with Isolated Severe Traumatic Brain Injury. World J Surg 2019; 43:2804-2811. [DOI: 10.1007/s00268-019-05072-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Frisoli FA, Shinseki M, Nwabuobi L, Zeng XL, Adrados M, Kanter C, Frangos SG, Huang PP. Early Venous Thromboembolism Chemoprophylaxis After Traumatic Intracranial Hemorrhage. Neurosurgery 2018; 81:1016-1020. [PMID: 28973510 DOI: 10.1093/neuros/nyx164] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 05/23/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Venous thromboembolism is a common complication of traumatic brain injury with an estimated incidence of 25% when chemoprophylaxis is delayed. The timing of initiating prophylaxis is controversial given the concern for hemorrhage expansion. OBJECTIVE To determine the safety of initiating venous thromboembolic event (VTE) chemoprophylaxis within 24 h of presentation. METHODS We performed a retrospective analysis of patients with traumatic intracranial hemorrhage presenting to a level I trauma center. Patients receiving early chemoprophylaxis (<24 h) were compared to the matched cohort of patients who received heparin in a delayed fashion (>48 h). The primary outcome of the study was radiographic expansion of the intracranial hemorrhage. Secondary outcomes included VTE, use of intracranial pressure (ICP) monitoring, delayed decompressive surgery, and all-cause mortality. RESULTS Of 282 patients, 94 (33%) received chemoprophylaxis within 24 h of admission. The cohorts were evenly matched across all variables. The primary outcome occurred in 18% of patients in the early cohort compared to 17% in the delayed cohort (P = .83). Fifteen patients (16%) in the early cohort underwent an invasive procedure in a delayed fashion; this compares to 35 patients (19%) in the delayed cohort (P = .38). Five patients (1.7%) in our study had a VTE during their hospitalization; 2 of these patients received early chemoprophylaxis (P = .75). The rate of mortality from all causes was similar in both groups. CONCLUSION Early (<24 h) initiation of VTE chemoprophylaxis in patients with traumatic intracranial hemorrhage appears to be safe. Further prospective studies are needed to validate this finding.
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Affiliation(s)
- Fabio A Frisoli
- Department of Neurosurgery, New York University School of Medicine, New York, New York
| | - Matthew Shinseki
- Department of Neurosurgery, New York University School of Medicine, New York, New York
| | - Lynda Nwabuobi
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Xiaopei L Zeng
- Department of Surgery, Division of Trauma and Acute Care Surgery, Bellevue Hospital Center, New York, New York
| | - Murillo Adrados
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Carolyn Kanter
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Spiros G Frangos
- Department of Surgery, Division of Trauma and Acute Care Surgery, Bellevue Hospital Center, New York, New York
| | - Paul P Huang
- Department of Neurosurgery, Bellevue Hospital Center, New York, New York
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13
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A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury. Can J Neurol Sci 2018; 45:432-444. [PMID: 29895339 DOI: 10.1017/cjn.2017.275] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous thromboprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the postinjury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion. METHODS MEDLINE and EMBASE databases were searched. Inclusion criteria were studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers' levels of evidence. Randomized controlled trials were assessed for bias according to the Cochrane Collaboration Tool and Cohort studies were evaluated for bias using the Newcastle-Ottawa Scale. We performed univariate meta-regression analysis in an attempt to identify a relationship between VTEp timing and hemorrhagic progression and assess study heterogeneity using an I 2 statistic. RESULTS Twenty-one studies were included in the systematic review. Eighteen total studies demonstrated that VTEp postinjury in patients with stable head computed tomography scan does not lead to TBI progression. Fourteen studies demonstrated that VTEp administration 24 to 72 hours postinjury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive intracranial hemorrhage. Overall, meta-regression analysis demonstrated that there was no relationship between rate of hemorrhagic progression and VTEp timing. CONCLUSIONS Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.
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14
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Zacharia BE, Youngerman BE, Bruce SS, Hershman DL, Neugut AI, Bruce JN, Wright JD. Quality of Postoperative Venous Thromboembolism Prophylaxis in Neuro-oncologic Surgery. Neurosurgery 2017; 80:73-81. [PMID: 27258769 DOI: 10.1227/neu.0000000000001270] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 02/28/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Given the vagaries of published guidelines and the lack of high-quality evidence on the method, timing, and dose of venous thromboembolism (VTE) prophylaxis in neurological surgery, little is known about practice patterns regarding VTE prophylaxis in the United States. OBJECTIVE To estimate the use of VTE prophylaxis in patients who underwent surgery for a cerebral neoplasm and to identify patient, physician, and hospital characteristics associated with prophylaxis. METHODS Using the Premier Perspective database, we classified patients undergoing surgery for intracranial neoplasm between 2006 and 2012 on the basis of the type of VTE prophylaxis they received (mechanical, pharmacological, or combination). Generalized estimating equations were used to analyze the effects of pretreatment patient and system variables, including hospital and surgeon volume, on prophylaxis while controlling for hospital clustering. RESULTS A total of 43 327 patients were identified. Venous thromboembolism prophylaxis was given to 70.2% of patients. Overall, 16 957 (39.2%) had only mechanical prophylaxis, 5628 (13%) received only pharmacological prophylaxis, and 7826 (18.1%) received combination prophylaxis. Patients with high-volume providers (odds ratio, 2.22; 95% confidence interval, 1.33-3.69) were more likely to receive prophylaxis. CONCLUSION Nearly one-third of patients who underwent surgery for an intracranial tumor did not receive any VTE prophylaxis. We noted that the rate of overall VTE prophylaxis did not significantly change over the course of the 7 years analyzed despite an increasing focus on complication prevention. High-volume surgeons were more likely to provide VTE prophylaxis.
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Affiliation(s)
- Brad E Zacharia
- Department of Neurosurgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Brett E Youngerman
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Samuel S Bruce
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | | | | | - Jeffrey N Bruce
- Department of Neurological Surgery, Herbert Irving Comprehensive Cancer Center, New York Presbyterian Hospital-Columbia University Medical Center, New York, New York
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
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15
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Postoperative Thromboembolic Prophylaxis with Low-Molecular-Weight Heparin and Risk of Rebleeding in Patients with Chronic Subdural Hematomas: A Comparative Retrospective Cohort Study. World Neurosurg 2017; 104:284-290. [PMID: 28478248 DOI: 10.1016/j.wneu.2017.04.154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Early postoperative administration of low-molecular-weight heparin (LMWH) to prevent thromboembolic events in patients with chronic subdural hematoma (CSDH) is controversial. Our goal was to investigate impact of early postoperative LMWH administration on recurrence rate of CSDHs. METHODS Retrospective review was performed of 136 patients with CSDHs who were operated on during an 18-month period. Early postoperative administration of LMWH was at the discretion of the treating surgeon. This resulted in patients treated (heparin [H] group) or not treated with LMWH (no heparin [NH] group). All patients underwent imaging 4 weeks after surgery or earlier in cases of deterioration. The primary outcome variable was reoperation. Secondary outcomes were reoperation, important residual hematoma (defined as hematoma depth of more than one third of original size), and incidence of thromboembolic complications. Relative risk and absolute risk reduction were calculated. RESULTS We included 105 patients, 50 (47.6%) in the NH group and 55 (52.4%) in the H group. Nine patients (18%) in the NH group and 6 patients (10.9%) in the H group required secondary surgery (relative risk 0.61, 95% confidence interval 0.23-1.58, P = 0.404, absolute risk reduction 0.07). Eleven patients (22%) in the NH group and 15 patients (27.3%) in the H group presented with important residual hematoma or underwent surgery for hematoma recurrence (relative risk 1.24, 95% confidence interval 0.63-2.44, P = 0.532, absolute risk reduction -0.05). CONCLUSIONS Our data provide preliminary evidence that early postoperative administration of LWMH does not increase risk of clinically relevant recurrence of CSDHs.
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16
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Dunham CM, Huang GS. Lethal Trauma Pulmonary Embolism is a Black Swan Event in Patients at Risk for Deep Vein Thrombosis: An Evidence-Based Review. Am Surg 2017. [DOI: 10.1177/000313481708300431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We delineated the incidence of trauma patient pulmonary embolism (PE) and risk conditions by performing a systematic literature review of those at risk for deep vein thrombosis (DVT). The PE proportion was 1.4 per cent (95% confidence interval = 1.2–1.6) in at-risk patients. Of 10 conditions, PE was only associated with increased age (P < 0.01) or leg injury (P < 0.01; risk ratio = 1.6). As lower extremity DVT (LEDVT) proportions increased, mortality proportions (P = 0.02) and hospital stay (P = 0.0002) increased, but PE proportions did not (P = 0.13). LEDVT was lower with chemoprophylaxis (CP) (4.9%) than without CP (19.1%; P < 0.01). PEwas lower withCP (1.0%) than without CP (2.2%; P = 0.0004). Mortality was lower with CP (6.6%) than without CP (11.6%; P = 0.002). PE was similar with (1.2%) and without (1.9%; P = 0.19) mechanical prophylaxis (MP). LEDVT was lower with MP (8.5%) than without MP (12.2%; P = 0.0005). PE proportions were similar with (1.3%) and without (1.5%; P = 0.24) LEDVTsurveillance. Mortality was higher with LEDVTsurveillance (7.9%) than without (4.8%; P < 0.01). A PE mortality of 19.7 per cent (95% confidence interval = 18–22) 3 a 1.4 per cent PE proportion yielded a 0.28 per cent lethal PE proportion. As PE proportions increased, mortality (P = 0.52) and hospital stay (P = 0.13) did not. Of 176 patients with PE, 76 per cent had no LEDVT. In trauma patients at risk for DVT, PE is infrequent, has a minimal impact on outcomes, and death is a black swan event. LEDVTsurveillance did not improve outcomes. Because PE was not associated with LEDVT and most patients with PE had no LEDVT, preventing, diagnosing, and treating LEDVT may be ineffective PE prophylaxis.
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Affiliation(s)
- C. Michael Dunham
- General Surgery/Trauma Services/Surgical Critical Care, St. Elizabeth Youngstown Hospital, Youngstown, Ohio
| | - Gregory S. Huang
- General Surgery/Trauma Services/Surgical Critical Care, St. Elizabeth Youngstown Hospital, Youngstown, Ohio
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17
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Dengler BA, Mendez-Gomez P, Chavez A, Avila L, Michalek J, Hernandez B, Grandhi R, Seifi A. Safety of Chemical DVT Prophylaxis in Severe Traumatic Brain Injury with Invasive Monitoring Devices. Neurocrit Care 2016; 25:215-23. [DOI: 10.1007/s12028-016-0280-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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A Systematic Review of the Benefits and Risks of Anticoagulation Following Traumatic Brain Injury. J Head Trauma Rehabil 2016; 30:E29-37. [PMID: 24992639 DOI: 10.1097/htr.0000000000000077] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To synthesize the existing literature on benefits and risks of anticoagulant use after traumatic brain injury (TBI). DESIGN Systematic review. A literature search was performed in MEDLINE, International Pharmaceutical Abstracts, Health Star, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) on October 11, 2012, and updated on September 2, 2013, using terms related to TBI and anticoagulants. MAIN MEASURES Human studies evaluating the effects of post-TBI anticoagulation on venous thromboembolism, hemorrhage, mortality, or coagulation parameters with original analyses were eligible for the review. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was followed throughout the conduct of the review. RESULTS Thirty-nine eligible studies were identified from the literature, of which 23 studies with complete information on post-TBI anticoagulant use and patient outcomes were summarized in this review. Meta-analysis was unwarranted because of varying methodological design and quality of the studies. Twenty-one studies focused on the effects of pharmacological thromboprophylaxis (PTP) post-TBI on venous thromboembolism and/or progression of intracranial hemorrhage, whereas 2 randomized controlled trials analyzed coagulation parameters as the result of anticoagulation. CONCLUSION Pharmacological thromboprophylaxis appears to be safe among TBI patients with stabilized hemorrhagic patterns. More evidence is needed regarding effectiveness of PTP in preventing venous thromboembolism as well as preferred agent, dose, and timing for PTP.
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19
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Cote DJ, Smith TR. Venous thromboembolism in brain tumor patients. J Clin Neurosci 2016; 25:13-8. [DOI: 10.1016/j.jocn.2015.05.053] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/15/2015] [Accepted: 05/22/2015] [Indexed: 10/22/2022]
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20
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Venous Thromboembolism in Brain Tumor Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:215-228. [DOI: 10.1007/5584_2016_117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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21
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Tsuda K, Nishii T, Sakai T, Takao M, Nakamura N, Sugano N. Thrombophylaxis with low-dose, short-term fondaparinux after elective hip surgery. J Thromb Thrombolysis 2015; 41:413-21. [PMID: 26184606 DOI: 10.1007/s11239-015-1249-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Some studies have cautioned about the possibility of bleeding complications with routine use of anticoagulants like fondaparinux (FPX) for thrombophylaxis after elective hip surgery. Overdosing or prolonged periods of anticoagulant use should be avoided. We trialed a new regimen using FPX and tranexamic acid (TA) to reduce the risk of bleeding complications while maintaining efficacy in preventing deep vein thrombosis (DVT). The present study evaluated the effectiveness and safety of this regimen in 391 consecutive patients. Each patient was assigned either the FPX group, administered a once-daily subcutaneous injection of 1.5 mg of FPX on postoperative days 2, 3, and 4; or the intermittent pneumatic compression (IPC) group, which used an IPC device continuously for 1-2 days with no administration of any anticoagulant drugs. Ultrasonography was performed to diagnose DVT in all patients. No cases of fatal or symptomatic pulmonary embolism were encountered in either group, but six patients (3.1 %) in the FPX group and nine patients (6.0 %) in the IPC group showed asymptomatic distal DVT. The incidence of DVT tended to be lower (p = 0.19), volumes of intraoperative (p < 0.01) and postoperative (p < 0.01) blood loss were significantly smaller, and hemoglobin level was significantly higher in the FPX group than in the IPC group (p < 0.01). Our new thrombophylactic regimen using FPX and TA appears effective and safe for use after elective hip surgery.
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Affiliation(s)
- Kosuke Tsuda
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, Japan.
| | - Takashi Nishii
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, Japan
| | - Takashi Sakai
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, Japan
| | - Masaki Takao
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, Japan
| | - Nobuo Nakamura
- Center of Arthroplasty, Kyowakai Hospital, 1-24-1 Kishibe-kita, Suita, Osaka, Japan
| | - Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, Japan
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22
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Abdel-Aziz H, Dunham CM, Malik RJ, Hileman BM. Timing for deep vein thrombosis chemoprophylaxis in traumatic brain injury: an evidence-based review. Crit Care 2015; 19:96. [PMID: 25887600 PMCID: PMC4372323 DOI: 10.1186/s13054-015-0814-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Multiple studies have addressed deep vein thrombosis chemoprophylaxis timing in traumatic brain injuries. However, a precise time for safe and effective chemoprophylaxis is uncertain according to experts. A comprehensive literature review on brain injuries was performed to delineate temporal proportions for 1) spontaneous intracranial hemorrhage (ICH) progression, 2) post-chemoprophylaxis ICH expansion, and 3) post-chemoprophylaxis deep vein thrombosis. Twenty-three publications were found including more than 5,000 patients. Spontaneous ICH expansion at 24 hours was 14.8% in 1,437 patients from chemoprophylaxis studies and 29.9% in 1,257 patients not in chemoprophylaxis studies (P < 0.0001). With low-risk ICH (n = 136), 99% of spontaneous ICH expansion occurred within 48 hours. In moderate or high-risk ICH (n = 109), 18% of spontaneous ICH expansion occurred after day 3. If patients with pre-chemoprophylaxis ICH expansion are included, the post-chemoprophylaxis ICH expansion proportion was 5.6% in 1,258 patients with chemoprophylaxis on days 1 to 3 and was 1.5% in 401 with chemoprophylaxis after day 3 (P = 0.0116). If patients with pre-chemoprophylaxis ICH expansion were excluded, the post-chemoprophylaxis ICH expansion proportion was 3.1% in 1,570 patients with chemoprophylaxis on days 1 to 3 and was 2.8% in 582 with chemoprophylaxis after day 3 (P = 0.7769). In diffuse axonal injury (n = 188), the post-chemoprophylaxis ICH expansion proportion was 1.6% with chemoprophylaxis after day 3. The deep vein thrombosis proportions were as follows: chemoprophylaxis on days 1 to 3, 2.6% in 2,384 patients; chemoprophylaxis on days 4 or 5, 2.2% in 831; and chemoprophylaxis on day 8, 14.1% in 99 (P < 0.0001). Spontaneous ICH expansion proportions at 24 hours substantially vary between chemoprophylaxis and non-chemoprophylaxis studies. Chemoprophylaxis should not be given within 3 days of injury for moderate-risk or high-risk ICH. Chemoprophylaxis is reasonable when low-risk patients have not developed ICH expansion within 48 hours post-injury. Chemoprophylaxis is also acceptable after day 3, when low-risk patients develop ICH expansion within 48 hours post-injury. In diffuse axonal injury patients who have not developed ICH within 72 hours, chemoprophylaxis is reasonable. Deep vein thrombosis proportions significantly increase when chemoprophylaxis is withheld for greater than 7 days.
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Affiliation(s)
- Hiba Abdel-Aziz
- General Surgery/Trauma Services/Surgical Critical Care, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
| | - C Michael Dunham
- General Surgery/Trauma Services/Surgical Critical Care, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
| | - Rema J Malik
- General Surgery/Trauma Services/Surgical Critical Care, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
| | - Barbara M Hileman
- General Surgery/Trauma Services/Surgical Critical Care, St Elizabeth Health Center, 1044 Belmont Avenue, Youngstown, OH, 44501, USA.
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23
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Prabhakaran S, Herbers P, Khoury J, Adeoye O, Khatri P, Ferioli S, Kleindorfer DO. Is Prophylactic Anticoagulation for Deep Venous Thrombosis Common Practice After Intracerebral Hemorrhage? Stroke 2015; 46:369-75. [DOI: 10.1161/strokeaha.114.008006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Prophylactic anticoagulation for deep venous thrombosis prevention after intracerebral hemorrhage (ICH) is safe. Current guidelines recommend prophylactic anticoagulation after cessation of hematoma growth. We aimed to evaluate nationwide trends in deep venous thrombosis prophylaxis after ICH.
Methods—
In an analysis of the Premier database, we identified adult patients with ICH (
International Classification of Diseases
Ninth edition code 431) from 2006 to 2010 who survived to day 2 of hospitalization. We excluded those with trauma or who underwent craniotomy or angiography. We abstracted type of anticoagulant used and date of first administration. We used univariate statistics and multivariable logistic regression to assess factors associated with prophylactic anticoagulation after ICH.
Results—
Among 32 690 (mean age, 69.7 years; 50.1% men) patients with spontaneous ICH, 5395 (16.5%) patients received any prophylactic anticoagulation during the hospital stay. Among these patients, 2416 (44.8%) received prophylactic anticoagulation by day 2. The most commonly used agents were heparin (71.1%), enoxaparin (27.5%), and dalteparin (1.4%). The proportion of patients receiving prophylactic anticoagulation increased slightly during the study period from 14.3% to 18.0% (
P
<0.01 for trend). Use of prophylactic anticoagulation varied by geographic region (
P
<0.001) in the United States: Northeast (23.2%), South (19.0%), Midwest (10.8%), and West (9.8%). In multivariable analysis, geographic region remained an independent predictor of prophylactic anticoagulation.
Conclusions—
Less than 20% of patients with ICH receive anticoagulation for deep venous thrombosis in the United States. When used, the time to initiation is <2 days in less than half of the patients. Further study should focus on understanding variations in practice and emphasize guideline-driven care.
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Affiliation(s)
- Shyam Prabhakaran
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Patricia Herbers
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Jane Khoury
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Opeolu Adeoye
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Pooja Khatri
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Simona Ferioli
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
| | - Dawn O. Kleindorfer
- From the Department of Neurology, Northwestern University, Chicago, IL (S.P.); Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH (P.H., J.K.); and Department of Neurology, University of Cincinnati, OH (O.A., P.K., S.F., D.O.K.)
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Raychaudhuri R, Litofsky NS. Which traumatic brain injury patients should be treated with anticoagulants and when? Expert Rev Neurother 2014; 14:237-9. [DOI: 10.1586/14737175.2014.888652] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Reduction of thromboembolic events in meningioma surgery: a cohort study of 724 consecutive patients. PLoS One 2013; 8:e79170. [PMID: 24244441 PMCID: PMC3828295 DOI: 10.1371/journal.pone.0079170] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 09/25/2013] [Indexed: 01/08/2023] Open
Abstract
Background Meningiomas are associated with the highest postoperative rate of venous thromboembolic events (VTE) among all intracranial tumors. The aim of this study is to compare two entirely different VTE prophylaxis regimens in 724 consecutive patients undergoing meningioma surgery. Methods Two cohorts at a single institution treated with different regimens to prevent VTE were reviewed retrospectively. Cohort A (n = 482; 314 females, mean age 57 years, range: 11–87 years) received our institutional regimen during the years 1999–2006, consisting of low-molecular-weight heparin (LMWH) and compression stockings. For cohort B (n = 242; 163 females, mean age 56.8 years, range: 16–90 years), during the years 2008–2010, the management included intraoperative 10°–20° leg elevation with intermittent pneumatic compression (IPC), heparin and LMWH administration. We compared the incidence of the endpoints pulmonary embolism (PE), deep venous thrombosis (DVT), hemorrhage and death, taking into account several known associated risk factors. Results For all endpoints, we observed a more favorable outcome with the new regimen. The difference in incidence of PEs (cohort A: 38/482, 8%; cohort B: 6/242, 2.5%) reached statistical significance (p = 0.002). In general, patients with skull base meningiomas had a higher risk for PE (OR 2.77). Regarding VTE prophylaxis, an adjusted subgroup analysis suggests that the new regimen is particularly beneficial for patients with skull base meningiomas. Conclusions We recommend perioperative prophylaxis using a management composed of intraoperative leg-elevation, IPC, early heparin administration and LMWH to reduce the risk for PE.
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Jamjoom AA, Jamjoom AB. Safety and Efficacy of Early Pharmacological Thromboprophylaxis in Traumatic Brain Injury: Systematic Review and Meta-Analysis. J Neurotrauma 2013; 30:503-11. [DOI: 10.1089/neu.2012.2584] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aimun A.B. Jamjoom
- Department of Clinical Neuroscience, Western General Hospital, Edinburgh, United Kingdom
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Abstract
Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.
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29
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Mohseni S, Talving P, Lam L, Chan LS, Ives C, Demetriades D. Venous thromboembolic events in isolated severe traumatic brain injury. J Emerg Trauma Shock 2012; 5:11-5. [PMID: 22416148 PMCID: PMC3299146 DOI: 10.4103/0974-2700.93102] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 08/03/2011] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the effect of prophylactic anticoagulation on the incidence of venous thromboembolic events (VTE) in patients suffering from isolated severe traumatic brain injury (TBI). MATERIALS AND METHODS Retrospective matched case-control study in adult patients sustaining isolated severe TBI (head AIS ≥3, with extracranial AIS ≤2) receiving VTE prophylaxis while in the surgical intensive care unit from 1/2007 through 12/2009. Patients subjected to VTE prophylaxis were matched 1:1 by age, gender, glasgow coma scale (GCS) score at admission, presence of hypotension on admission, injury severity score, and head abbreviated injury scale (AIS) score, with patients who did not receive chemical VTE prophylaxis. The primary outcome measure was VTE. Secondary outcomes were SICU and hospital length of stay (HLOS), adverse effects of anticoagulation, and mortality. RESULTS After propensity matching, 37 matched pairs were analysed. Cases and controls had similar demographics, injury characteristics, rate of craniotomies/craniectomies, SICU LOS, and HLOS. The median time of commencement of VTE prophylaxis was 10 days. The incidence of VTE was increased 3.5-fold in the controls compared to the cases (95% CI 1.0-12.1, P=0.002). The mortality was higher in patients who did not receive anticoagulation (19% vs. 5%, P=0.001). No adverse outcomes were detected in the anticoagulated patients. CONCLUSION Prophylactic anticoagulation decreases the overall risk for clinically significant VTE in patients with severe isolated TBI. Prospective validation of the timing and safety of chemical VTE prophylaxis in these instances is warranted.
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Affiliation(s)
- Shahin Mohseni
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care at the Los Angeles County and University of Southern California Medical Center, Los Angeles, CA
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Masotti L, Godoy DA, Di Napoli M, Rabinstein AA, Paciaroni M, Ageno W. Pharmacological prophylaxis of venous thromboembolism during acute phase of spontaneous intracerebral hemorrhage: what do we know about risks and benefits? Clin Appl Thromb Hemost 2012; 18:393-402. [PMID: 22609819 DOI: 10.1177/1076029612441055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Spontaneous intracerebral hemorrhage (sICH) represents a devastating clinical event with high mortality and morbidity rates. Only few patients with sICH are treated with neurosurgical evacuation of the hematoma, and the majority of them need only a good conservative medical approach. The goal of medical treatment is to avoid secondary neurological and systemic complications. Venous thromboembolism (VTE) represents one of the most feared complications of sICH, and it is a potential cause of death. The balance between the benefit of VTE prevention and the risk of hematoma enlargement and/or rebleeding with the use of pharmacologic thromboprophylaxis remains controversial because of the lack of consistent evidences in the literature. The efficacy of mechanical prophylaxis is also uncertain. Consequently, until now there are no clear guidelines and scientific evidences available for physicians in this field. The aim of this review is to analyze the available literature and guidelines about pharmacological VTE prophylaxis in patients with nonsurgical sICH.
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Affiliation(s)
- Luca Masotti
- Internal Medicine, Cecina Hospital, Cecina, Italy.
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31
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Nitta N, Shitara S, Nozaki K. Heparin-induced thrombocytopenia in a glioblastoma multiforme patient with inferior vena cava filter placement for deep venous thrombosis. Neurol Med Chir (Tokyo) 2011; 51:445-8. [PMID: 21701111 DOI: 10.2176/nmc.51.445] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 58-year-old woman presented with right supplementary motor area glioblastoma multiforme and deep venous thrombosis in her legs. The tumor was resected after temporary inferior vena cava filter placement, considering that increased thrombosis during and after the operation would cause fatal pulmonary embolism. After anticoagulation with unfractionated heparin, thrombocytopenia was aggravated, and computed tomography showed filter catheter-related thrombosis in the inferior vena cava. The diagnosis was heparin-induced thrombocytopenia, and argatroban and urokinase were administered. Thrombolysis with urokinase was completed and the temporary inferior vena cava filter catheter was removed without complication. The present case illustrates the possibility of heparin-induced thrombocytopenia associated with catheter-related thrombosis in neurosurgery.
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Affiliation(s)
- Naoki Nitta
- Department of Neurosurgery, Shiga University of Medical Science, Shiga, Japan.
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Paciaroni M, Agnelli G, Venti M, Alberti A, Acciarresi M, Caso V. Efficacy and safety of anticoagulants in the prevention of venous thromboembolism in patients with acute cerebral hemorrhage: a meta-analysis of controlled studies. J Thromb Haemost 2011; 9:893-8. [PMID: 21324058 DOI: 10.1111/j.1538-7836.2011.04241.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The role of anticoagulants for the prevention of venous thromboembolism in acute hemorrhagic stroke is uncertain. We performed an updated meta-analysis of studies to obtain the best estimates of the efficacy and safety of anticoagulants for the prevention of venous thromboembolism in patients with acute hemorrhagic stroke. METHODS Using electronic and manual searches of the literature, we identified randomized and non-randomized studies comparing anticoagulants (unfractionated heparin or low-molecular-weight heparin or heparinoids) with treatments other than anticoagulants (elastic stockings, intermittent pneumatic compression or placebo) in patients with acute hemorrhagic stroke. Study outcomes included symptomatic and asymptomatic deep venous thrombosis (DVT), symptomatic and asymptomatic pulmonary embolism (PE), any hematoma enlargement or death. Risk ratios (RRs) for individual outcomes were calculated for each study and data from all studies were pooled using the Mantel-Haenszel method. RESULTS Four studies (two randomized) involving 1000 patients with acute hemorrhagic stroke met the criteria for inclusion in this meta-analysis. Compared with other treatments, anticoagulants were associated with a significant reduction in PE (1.7% vs. 2.9%; RR, 0.37; 95% CI, 0.17-0.80; P = 0.01), a DVT rate of 4.2% compared with 3.3% (RR, 0.77; 95% CI, 0.44-1.34; P = 0.36), an increase in any hematoma enlargement (8.0% vs. 4.0%; RR, 1.42; 95% CI, 0.57-3.53; P = 0.45), and a non-significant reduction in mortality (16.1% vs. 20.9%; RR, 0.76; 95% CI, 0.57-1.03; P = 0.07). CONCLUSIONS Our findings indicate that in patients with hemorrhagic stroke, early anticoagulation is associated with a significant reduction in PE and a non-significant reduction in mortality, with the trade-off of a non-significant increase in hematoma enlargement. These results must be taken with caution and should encourage the assessment of the clinical benefit of antithrombotic prophylaxis in patients with cerebral bleeding by properly designed clinical trials.
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Affiliation(s)
- M Paciaroni
- Stroke Unit, Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy.
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Is early venous thromboembolism prophylaxis safe in trauma patients with intracranial hemorrhage. ACTA ACUST UNITED AC 2011; 70:324-9. [PMID: 21307729 DOI: 10.1097/ta.0b013e31820b5d22] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients with traumatic brain injuries (TBIs) are at high risk for venous thromboembolic sequelae; however, prophylaxis is often delayed because of the perceived risk of intracranial hemorrhagic exacerbation. The goal of this study was to determine whether enoxaparin for early venous thromboembolism (VTE) prophylaxis is safe for hemodynamically stable patients with TBIs. METHODS This is a retrospective cohort study from a Level I Trauma Center of patients with TBIs receiving early (0-72 hours) or late (>72 hours) VTE prophylaxis. Inclusion criteria included evidence of acute intracranial hemorrhagic injury (IHI) on admission computed tomography, head/neck abbreviated injury score≥3, age≥16 years, and hospital length of stay≥72 hours. Exclusion criteria included intracranial pressure monitor/ventriculostomy, current systemic anticoagulation, pregnancy, coagulopathy, history of DVT, ongoing intra-abdominal hemorrhage 24 hours postadmission, and preexisting inferior vena cava filter. Progression of IHI defined as lesion expansion/new IHI on repeat computed tomography. RESULTS Totally, 669 patients were identified: 268 early (40.1%) and 401 late (59.9%), with a mean injury severity score of 27.8±10.2 and 29.4±11, respectively. Head neck abbreviated injury score of 3 (47% vs. 34%), 4 (42% vs. 46%), 5 (11% vs. 19%), and 6 (0% vs. 1%) were reported for the early and late treatment groups, respectively. Mean time to prophylaxis was 2.77 days±0.49 days and 5.31 days±1.97 days. IHI progression before prophylaxis was 9.38% versus 17.41% (p<0.001) and after prophylaxis was 1.46% versus 1.54% (p>0.9). Proportions of proximal DVT were 1.5% versus 3.5% (p=0.117) and pulmonary embolism were 1.5% versus 2.2% (p=0.49). There were no differences in injury severity score, age, and pelvic and/or long bone fractures. CONCLUSIONS We found no evidence that early VTE prophylaxis increases the rate of IHI progression in hemodynamically stable patients with TBIs. The natural rate of IHI progression observed is comparable with previous studies. Although not powered to detect differences in the incidence of DVT and pulmonary embolism, the data trend toward increased proportions of both VTE outcomes in the late group.
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Dudley RR, Aziz I, Bonnici A, Saluja RS, Lamoureux J, Kalmovitch B, Gursahaney A, Razek T, Maleki M, Marcoux J. Early venous thromboembolic event prophylaxis in traumatic brain injury with low-molecular-weight heparin: risks and benefits. J Neurotrauma 2011; 27:2165-72. [PMID: 20939698 DOI: 10.1089/neu.2010.1366] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury (TBI) patients are known to be at high risk for venous thromboembolic events (VTEs). The Brain Trauma Foundation Guidelines (2007) state that low-molecular-weight heparin or unfractionated heparin should be used to prevent VTE complications, but suggest that there is an increased risk of expansion of intracranial hemorrhages (ICH) with VTE prophylaxis. In addition, it is unclear which treatment regimen (i.e., medication, dose, and timing) provides the best risk:benefit ratio in TBI patients. We reviewed all moderate-to-severe TBI patients admitted over a 5-year period to: (1) examine the occurrence of VTEs and their timing; (2) examine the symptomatic expansion of ICH while on VTE prophylaxis; and (3) compare the efficacy of two prophylactic agents: enoxaparin and dalteparin. Two-hundred eighty-seven patients were included. VTE prophylaxis was started 48-72 h post-trauma in all individuals who had no confounding coagulopathy, when two consecutive computed tomography (CT) scans revealed hemorrhage stability. VTEs occurred in 7.3% of treated patients, mostly within 2 weeks after trauma. Proximal VTEs occurred in 3.1% of treated patients. No significant difference in VTE rates was seen between enoxaparin (7.0%) and dalteparin (7.5%; p = 0.868). Moreover, the group treated with dalteparin was more severely injured (higher Injury Severity Score [p = 0.002]), had lower Glasgow Coma Scale (GCS) scores (p = 0.003), and had more inferior vena cava (IVC) filters placed (p = 0.007). The two groups did not show significant differences in the development of VTE when controlled for ISS and IVC filters (p = 0.819). Importantly, only one patient suffered a symptomatic expansion of ICH while on VTE prophylaxis, at 15 days post-trauma. These results suggest that current regimens of VTE prophylaxis used in our TBI population provide a relatively high level of protection against VTEs, and an extremely low risk of expanding ICH. They also suggest that there was no difference in VTE between dalteparin- and enoxaparin-treated patients.
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Affiliation(s)
- Roy R Dudley
- Montreal Neurological Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Postoperative intracranial haemorrhage: a review. Neurosurg Rev 2011; 34:393-407. [DOI: 10.1007/s10143-010-0304-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 09/27/2010] [Accepted: 11/10/2010] [Indexed: 01/31/2023]
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Pahatouridis D, Alexiou GA, Zigouris A, Mihos E, Drosos D, Voulgaris S. Coagulopathy in moderate head injury. The role of early administration of low molecular weight heparin. Brain Inj 2011; 24:1189-92. [PMID: 20642324 DOI: 10.3109/02699052.2010.490510] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Abnormalities in blood coagulation are relatively common after traumatic brain injury (TBI). We prospectively studied the safety of the early antithrombotic prophylaxis with low molecular weight heparin. METHODS We prospectively evaluated 61 patients with moderate TBI. Patients requiring surgical treatment and/or with injuries in other systems were excluded. Coagulation studies included among others prothrombin time (PT), plasma fibrinogen levels and D-dimer levels. Blood samples were collected on admission and 24 h, 48 h, and 72 h later. Prophylaxis was started within 24 hours with tinzaparin. RESULTS In 42 of 61 patients a form of disseminated intravascular coagulation (DIC) was detected. The severity of head injury was correlated with the severity of the coagulation disorders. The PT was prolonged in the first two days. Plasma fibrinogen levels dropped initially and increased to above normal values 2-3 days later. D-dimer levels were significantly elevated and in 19 patients remained elevated throughout the study period. Clinical manifestations of DIC were not observed. CONCLUSIONS Patients with moderate TBI are at a serious risk of developing brain intravascular microthrombosis. Our study supports the early use of low molecular weight heparin.
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Martin MJ, Blair KS, Curry TK, Singh N. Vena Cava Filters: Current Concepts and Controversies for the Surgeon. Curr Probl Surg 2010; 47:524-618. [DOI: 10.1067/j.cpsurg.2010.03.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Raslan AM, Fields JD, Bhardwaj A. Prophylaxis for venous thrombo-embolism in neurocritical care: a critical appraisal. Neurocrit Care 2010; 12:297-309. [PMID: 20033354 DOI: 10.1007/s12028-009-9316-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Venous thrombo-embolism (VTE) is frequently encountered in critically ill neurological and neurosurgical patients admitted to intensive care units. This patient population includes those with brain neoplasm, intracranial hemorrhage, ischemic stroke, subarachnoid hemorrhage, pre- and post-operative patients undergoing neurosurgical procedures and those with traumatic brain injury, and acute spinal cord injury (SCI). There is a wide variability in clinical practice for thromboprophylaxis in these patients, in part due to paucity of data based on randomized clinical trials. Here, we review the current literature on the incidence of VTE in the critically ill neurological and neurosurgical patients as well as appraise available data to support particular practice paradigms for specific subsets of these patients. Data synthesis was conducted via search of Medline, Cochrane databases, and manual review of article bibliographies. Critically ill neurological and neurosurgical patients have higher susceptibility to VTE. Intermittent compression devices with or without anti-thrombotics is generally the method of choice for thromboprophylaxis. Low molecular weight heparin is the method of choice in certain patient subgroups such as those with SCI and ischemic stroke. Inferior vena cava filters may play a role in thromboprophylaxis in selected cases. Without clear guidelines that can be universally applied to this diverse group of patients, prophylaxis for VTE should be tailored to the individual patient with cautious assessment of benefits versus risks. There is a need for higher level evidence to guide VTE prophylaxis in certain subgroups of this patient population.
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Affiliation(s)
- Ahmed M Raslan
- Department of Neurosurgery, Oregon Health & Science University, Portland, OR, USA
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Gerlach R, Krause M, Seifert V, Goerlinger K. Hemostatic and hemorrhagic problems in neurosurgical patients. Acta Neurochir (Wien) 2009; 151:873-900; discussion 900. [PMID: 19557305 DOI: 10.1007/s00701-009-0409-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 10/22/2008] [Indexed: 01/10/2023]
Abstract
BACKGROUND Abnormalities of the hemostasis can lead to hemorrhage, and on the other hand to thrombosis. Intracranial neoplasms, complex surgical procedures, and head injury have a specific impact on coagulation and fibrinolysis. Moreover, the number of neurosurgical patients on medication (which interferes with platelet function and/or the coagulation systems) has increased over the past years. METHOD The objective of this review is to recall common hemostatic disorders in neurosurgical patients on the basis of the "new concept of hemostasis". Therefore the pertinent literature was searched to provide a structured and up to date manuscript about hemostasis in Neurosurgery. FINDINGS According to recent scientific publications abnormalities of the coagulation system are discussed. Pathophysiological background and the rational for specific (cost)-effective perioperative hemostatic therapy is provided. CONCLUSIONS Perturbations of hemostasis can be multifactorial and maybe encountered in the daily practice of neurosurgery. Early diagnosis and specific treatment is the prerequisite for successful treatment and good patients outcome.
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Affiliation(s)
- Ruediger Gerlach
- Department of Neurosurgery, Johann Wolfgang Goethe University, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany.
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Kiphuth IC, Köhrmann M, Huttner HB, Schellinger PD. The safety and usefulness of low molecular weight heparins and unfractionated heparins in patients with acute stroke. Expert Opin Drug Saf 2009; 8:585-97. [DOI: 10.1517/14740330903150157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ray WZ, Strom RG, Blackburn SL, Ashley WW, Sicard GA, Rich KM. Incidence of deep venous thrombosis after subarachnoid hemorrhage. J Neurosurg 2009; 110:1010-4. [DOI: 10.3171/2008.9.jns08107] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to determine the efficacy of venous ultrasonography in screening for deep venous thrombosis (DVT) after subarachnoid hemorrhage (SAH). A large cohort of patients who had suffered SAH was evaluated with the primary end points of ascertaining the incidence of asymptomatic DVT with venous Doppler ultrasonography screening and of identifying risk factors for the development of DVT and subsequent pulmonary embolism.
Methods
Data from patients with aneurysmal SAH who had been admitted to the neurosurgical intensive care unit (ICU) between December 2002 and October 2006 were retrospectively evaluated. Patients who had undergone surgical or endovascular treatment of an aneurysm following SAH and survived ≥ 15 days were included in the study.
Results
The overall incidence of DVT among the entire study cohort was 18%. A subgroup analysis identified all patients, with or without symptoms for DVT, who had undergone venous Doppler ultrasonography screening. The incidence of asymptomatic DVT was 24%. Univariate analysis of all patients revealed a significant correlation between the risk of DVT and Hunt and Hess grade (r = 0.38, p < 0.0001), Fisher grade (r = 0.31, p < 0.0001), total hospital stay (r = 0.49, p < 0.0001), and number of days in the ICU (r = 0.48, p < 0.0001). Multivariate analysis demonstrated that the total hospital stay and number of days in the ICU were significant predictors of DVT in all patients (p < 0.0001 and p < 0.0002, respectively). In the subgroup of screened patients, Hunt and Hess grade, total hospital stay, and number of days in the ICU were significant predictors of DVT. Although screened patients were more likely to have DVT (χ2 = 6.0976, p < 0.02), there was no significant difference in the incidence of DVT or pulmonary embolism between patients who did and those who did not undergo routine lower-extremity Doppler ultrasonography screening.
Conclusions
Routine compressive venous Doppler ultrasonography is an efficient, noninvasive means of identifying DVT as a screening modality in both symptomatic and asymptomatic patients following aneurysmal SAH. The ability to confirm or deny the presence of DVT in this patient population allows one to better identify the indications for chemoprophylaxis. Prophylaxis for venous thromboembolism in neurosurgical patients is common. Emerging literature and anecdotal experience have exposed risks of complications with prophylactic anticoagulation protocols. The identification of patients at high risk—for example, those with asymptomatic DVT—will allow physicians to better assess the role of prophylactic anticoagulation.
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Affiliation(s)
| | - Russel G. Strom
- 2Washington University School of Medicine, St. Louis, Missouri
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Kim KS, Brophy GM. Symptomatic venous thromboembolism: incidence and risk factors in patients with spontaneous or traumatic intracranial hemorrhage. Neurocrit Care 2009; 11:28-33. [PMID: 19238588 DOI: 10.1007/s12028-009-9201-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 02/04/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objectives of this study are to determine the incidence of symptomatic venous thromboembolism (VTE) in neurosurgery intensive care unit (NSICU) patients with spontaneous or traumatic intracranial hemorrhage and to identify the common VTE risk factors by injury type. METHODS This retrospective, single-center cohort study included adult patients admitted to the NSICU between January 2001 and July 2004 with a primary diagnosis of subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), or traumatic brain injury (TBI). Patients and VTE events were identified using ICD-9 codes. All patients received low-dose unfractionated heparin or enoxaparin and intermittent pneumatic compression device. Descriptive statistics were used to describe patient characteristics. RESULTS The overall incidence of symptomatic VTE was 3.8% (n = 1195). The incidence of VTE was 6.7% in SAH patients (n = 179), 2.9% in ICH patients (n = 516), and 3.8% in TBI patients (n = 500). The most commonly identified risk factors in the three groups were: greater than 40 years of age, immobility due to paresis or restrictions for mechanical ventilation, presumed infection, and presence of indwelling central venous catheter. There was no objective evidence of intracranial bleeding associated with pharmacologic VTE prophylaxis in VTE patients. CONCLUSION This is the first study to determine symptomatic VTE incidence and to identify common risk factors by injury type in nontumor patients who are not routinely screened with venous duplex ultrasonography but receiving early IPC and LDUH. Further studies are needed to determine the overall incident of symptomatic and nonsymptomatic VTE and independent risk factors for VTE events in NSICU patients.
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Affiliation(s)
- Keri S Kim
- Department of Pharmacy Practice, University of Illinois Medical Center at Chicago, Chicago, IL, USA
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Rønning P, Sorteberg W, Nakstad P, Russell D, Helseth E. Aspects of intracerebral hematomas--an update. Acta Neurol Scand 2008; 118:347-61. [PMID: 18462476 DOI: 10.1111/j.1600-0404.2008.01023.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In Norway, there are approximately 16000 strokes each year and 15% of these are caused by intracerebral hematomas. Intracerebral hemorrhage (ICH) results from the rupture of blood vessels within the brain parenchyma. ICH occurs as a complication of several diseases, the most prevalent of which is chronic hypertension. When hemorrhage develops in the absence of a pre-existing vascular malformation or brain parenchymal lesion, it is denoted primary ICH. Secondary ICH refers to hemorrhage complicating a pre-existing lesion. Primary ICH is the most common type of hemorrhagic stroke, accounting for approximately 10% of all strokes. Despite aggressive management strategies, the 30-day mortality remains high, at almost 50%, with the majority of deaths occurring within the first 2 days. At 6 months, only 20-30% achieve independent status. MATERIAL AND METHODS This article is based on clinical experience, modern therapeutic guidelines for the treatment of intracerebral hematomas and up-to-date medical literature found in Medline. The article discusses the pathophysiology, clinical aspects, treatment, and the prognosis of intracerebral hematomas. RESULTS AND DISCUSSION Advances in diagnosis, prognosis, pathophysiology, and treatment over the past few decades have significantly advanced our knowledge of ICH; however, much work still needs to be carried out. Future genetic and epidemiologic studies will help identify at-risk populations and hopefully allow for primary prevention. Randomized controlled studies focusing on novel therapeutics should help to minimize secondary injury and hopefully improve morbidity and mortality.
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Affiliation(s)
- P Rønning
- Department of Neurosurgery, Ulleval Universitetssykehus, Oslo, Norway.
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Surani S, Estement B, Manchandan S, Sudhakaran S, Varon J. Spontaneous extraperitoneal lumbar artery hemorrhage. J Emerg Med 2008; 40:e111-4. [PMID: 18922660 DOI: 10.1016/j.jemermed.2008.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2007] [Revised: 01/02/2008] [Accepted: 01/17/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Spontaneous extraperitoneal hemorrhage (SEH) is an uncommon complication of anticoagulation therapy. Cases of SEH that are unresponsive to management through correction of coagulopathy, fluid resuscitation, blood transfusion, and other supportive measures are typically treated with surgery. Nevertheless, treatment of SEH with the use of angiography and arterial embolization may provide a safe, efficacious alternative to surgery. OBJECTIVES This case is presented to increase awareness among Emergency Physicians of the management options for patients with SEH. CASE REPORT A 67-year-old man presented to the Emergency Department with hemodynamic collapse due to retroperitoneal bleeding secondary to spontaneous rupture of a lumbar artery. An emergency abdominal angiogram revealed an actively bleeding left lumbar vessel. The localized bleeding was treated with catheter embolization and detachable microcoil embolization. This resulted in stabilization of the patient's condition without surgical intervention. CONCLUSION Overall, the improvement in hemodynamic stability and the decreased percentage of transfusion requirements can be achieved safely without surgical intervention through the prompt use of coil or catheter embolization.
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Affiliation(s)
- Salim Surani
- Texas A&M University, Corpus Christi, Texas, USA
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Cullen N, Bayley M, Bayona N, Hilditch M, Aubut J. Management of heterotopic ossification and venous thromboembolism following acquired brain injury. Brain Inj 2008; 21:215-30. [PMID: 17364532 DOI: 10.1080/02699050701202027] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of interventional strategies for the common complications of heterotopic ossification (HO) and venous thromboembolism (VTE) following acquired brain injury (ABI). METHODS AND MAIN OUTCOMES A systematic review of the literature from 1980-2005 was conducted focusing on interventions for HO and VTE in the ABI population. Nineteen studies examining a variety of treatment approaches were evaluated. RESULTS The majority of interventions are supported by limited evidence, defined as an absence of randomized controlled trials (RCTs). All of the treatment approaches for HO are supported with limited evidence. For VTE, there is moderate evidence, defined as at least one positive RCT, indicating that low-molecular-weight heparin is more effective than low-dose unfractionated heparin in preventing VTE, low-molecular-weight heparin is as effective and safe as unfractionated heparin for the prevention of pulmonary thromboembolism, low-molecular-weight heparin combined with compression stockings is more effective than compression stockings alone for the prevention of VTE and intermittent pneumatic compression devices are as effective as low-molecular-weight heparin for the prevention of VTE. CONCLUSIONS There are a variety of intervention and prophylactic strategies that have been postulated to treat and reduce the incidence of these complications, with the goal of improving rehabilitation outcomes. It is therefore important to investigate the efficacy of these treatment strategies to provide guidance for clinical practice based on the best available evidence.
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Affiliation(s)
- Nora Cullen
- Toronto Rehabilitation Institute, Toronto, Ontario.
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Meier C, Pfammatter T, Stocker R, Labler L, Benninger E, Lenzlinger P, Stover J, Trentz O, Imhof HG. Early Placement of Optional Vena Cava Filter in High-Risk Patients with Traumatic Brain Injury. Eur J Trauma Emerg Surg 2007; 33:407-13. [PMID: 26814735 DOI: 10.1007/s00068-007-6211-9] [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: 12/12/2006] [Accepted: 02/04/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Patients sustaining severe trauma are at high risk for the development of venous thromboembolic events (VTE). Pharmacologic VTE prophylaxis may be contraindicated early after trauma due to potential bleeding complications. The purpose of this study was to evaluate safety and feasibility of early prophylactic vena cava filter (VCF) placement and subsequent retrieval in multiple injured patients with traumatic brain injury (TBI). METHODS Analysis of single-institution case series of consecutive patients who received a prophylactic VCF after severe TBI (Abbreviated Injury Scale, AiS ≥ 3) between August 2003 and October 2006. RESULTS A total of 34 optional VCF were prophylactically placed with a median delay of 1 day after trauma (range, 0-7 days). All patients had sustained multiple injuries (median Injury Severity Score 41, range, 18-59) with severe TBI (median AiS 4, range 3-5). Median age was 41 years (range, 17-67 years). Two patients had succumbed before potential filter retrieval. Of the remaining patients, 27 (84%) had their filters uneventfully retrieved between 11 and 32 days (median, 18 days) after placement with no retrieval-related morbidity. Five VCF (16%) were left permanently. In one patient (3%) early inferior vena cava occlusion and deep venous thrombosis occurred 14 days after VCF placement. Symptomatic pulmonary embolism was observed in one patient (3%) 5 days after VCF retrieval. Overall trauma-related mortality was 9%. CONCLUSIONS Early VCF placement may be of benefit for multiple injured patients with TBI when pharmacologic VTE prophylaxis is contraindicated. VCF retrieval is safe and feasible. Filter placement- and retrieval-related morbidity is low.
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Affiliation(s)
- Christoph Meier
- Division of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland. .,Division of Trauma Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Thomas Pfammatter
- Institute of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Reto Stocker
- Division of Surgical Intensive Care, University Hospital Zurich, Zurich, Switzerland
| | - Ludwig Labler
- Division of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Emanuel Benninger
- Division of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Lenzlinger
- Division of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - John Stover
- Division of Surgical Intensive Care, University Hospital Zurich, Zurich, Switzerland
| | - Otmar Trentz
- Division of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Hans G Imhof
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
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Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, Manley GT, Nemecek A, Newell DW, Rosenthal G, Schouten J, Shutter L, Timmons SD, Ullman JS, Videtta W, Wilberger JE, Wright DW. V. Deep Vein Thrombosis Prophylaxis. J Neurotrauma 2007; 24 Suppl 1:S32-6. [PMID: 17511543 DOI: 10.1089/neu.2007.9991] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Gerber DE, Grossman SA, Streiff MB. Management of venous thromboembolism in patients with primary and metastatic brain tumors. J Clin Oncol 2006; 24:1310-8. [PMID: 16525187 DOI: 10.1200/jco.2005.04.6656] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism occurs commonly throughout the clinical course of patients with brain tumors. A number of hemostatic and clinical factors contribute to this hypercoagulable state. Concern over the possibility of intracranial bleeding has limited the use of anticoagulation in this population. However, mechanical approaches such as vena cava filters have high complication and treatment failure rates in patients with intracranial malignancies. In addition, the available data suggest that anticoagulation can be used safely and effectively in most of these patients. Patients with thrombocytopenia, recent neurosurgery, and tumor types prone to bleeding require special consideration. When intracranial hemorrhage does occur, it is often due to overanticoagulation, requiring prompt anticoagulation reversal and neurosurgical consultation.
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Affiliation(s)
- David E Gerber
- Departments of Oncology, Medicine, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Jochberger S, Mayr V, Luckner G, Fries DR, Mayr AJ, Friesenecker BE, Lorenz I, Hasibeder WR, Ulmer H, Schobersberger W, Dünser MW. Antifactor Xa activity in critically ill patients receiving antithrombotic prophylaxis with standard dosages of certoparin: a prospective, clinical study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R541-8. [PMID: 16277716 PMCID: PMC1297619 DOI: 10.1186/cc3792] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2005] [Revised: 06/16/2005] [Accepted: 07/17/2005] [Indexed: 11/10/2022]
Abstract
Introduction Deep venous thrombosis with subsequent pulmonary embolism or post-thrombotic syndrome is a feared complication in the intensive care unit. Therefore, routine prophylactic anticoagulation is widely recommended. Aside from unfractionated heparin, low molecular weight heparins, such as certoparin, have become increasingly used for prophylactic anticoagulation in critically ill patients. In this prospective study, we evaluated the potency of 3,000 IU certoparin administered once daily to reach antithrombotic antifactor Xa (aFXa) levels of 0.1 to 0.3 IU/ml in 62 critically ill patients. Methods AFXa levels were determined 4, 12 and 24 h after injection of certoparin. Prothrombin time, activated partial thromboplastin time, antithrombin, fibrinogen, hemoglobin, platelet count, serum urea and creatinine concentrations were documented before and 12 and 24 h after injection of certoparin. Results Four hours after certoparin injection (n = 32), 28% of patients were within the antithrombotic aFXa range. After 12 and 24 h, 6% achieved antithrombotic aFXa levels. Because of a severe pulmonary embolism in one study patient, an interim analysis was performed, and the dosage of certoparin was increased to 3,000 IU twice daily. This regime attained recommended antithrombotic aFXa levels in 47%, 27%, 40% and 30% of patients at 4, 12, 16 and 24 h, respectively, after twice daily certoparin injection (n = 30). Antithrombin and fibrinogen concentrations slightly increased during the observation period. Low antithrombin concentrations before certoparin were independently correlated with underdosing of certoparin. Patients with aFXa levels <0.1 IU/ml 4 h after certoparin injection required vasopressors more often and had lower serum concentrations of creatinine and urea than patients with antithrombotic aFXa levels. Conclusion Standard dosages of certoparin of 3,000 IU given once or twice daily are ineffective for attaining the recommended aFXa levels of 0.1 to 0.3 IU/ml in critically ill patients. Low antithrombin levels before certoparin administration were independently associated with low aFXa levels. Renal function and vasopressor therapy may further influence the effectiveness of certoparin in ensuring adequate antithrombotic prophylaxis.
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Affiliation(s)
- Stefan Jochberger
- Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.
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