Early detection of venous thromboembolism in patients with neuroepithelial tumor: efficacy of screening with serum d-dimer measurements and Doppler ultrasonography

A prospective study to evaluate the use of surveillance venous ultrasonography to detect incidence of deep venous thrombosis following neurosurgical excision of brain tumors

Objectives

Patients with brain tumors are prone to develop deep venous thrombosis (DVT) following neurosurgical excision of tumor. However, there is a deficiency of knowledge about the screening method, optimum frequency, and duration of the surveillance to diagnose DVT in the post-operative period. The primary objective was to find the incidence of DVT and associated risk factors. The secondary objectives were to find the optimum duration and frequency of surveillance venous ultrasonography (V-USG) in patients undergoing neurosurgery.

Materials and Methods

Hundred consecutive adult patients undergoing neurosurgical excision of brain tumors were included after their consent, over a period of 2 years. The risk factors for DVT were assessed in all the patients preoperatively. All patients underwent surveillance duplex V-USG of the upper and lower limbs at pre-planned time intervals in the perioperative period, by experienced radiologists and anesthesiologists. The occurrence of DVT was noted using the objective criteria. The association between the perioperative variables and the incidence of DVT was assessed using univariate logistic regression analysis.

Results

The most common prevalent risk factors were - malignancy (97%), major surgery (100%), and age >40 years (30%). Asymptomatic DVT was detected in the right femoral vein in one patient who underwent suboccipital craniotomy for high-grade medulloblastoma, on the 4th and 9th postoperative day, making the incidence of DVT 1%. The study found no association with perioperative risk factors and could not suggest the optimum duration and frequency of surveillance V-USG.

Conclusion

A low incidence of DVT (1%) was detected in patients undergoing neurosurgeries for brain tumors. Prevalent thromboprophylaxis practices and a shorter period of post-operative surveillance could be the reasons for the low incidence of DVT.

Elevated ratio of C-type lectin-like receptor 2 level and platelet count (C2PAC) aids in the diagnosis of post-operative venous thromboembolism in IDH-wildtype gliomas

INTRODUCTION

Podoplanin (PDPN) is known to induce platelet aggregation via interacting with the C-type lectin-like receptor-2 on platelets and is involved in postoperative venous thromboembolism (VTE) formation. In this study, we investigate the correlation between soluble C-type lectin-like receptor (sCLEC-2) levels and PDPN expression in patients with high grade gliomas and the relationship between sCLEC-2 levels and the occurrence of VTE.

MATERIALS AND METHODS

Forty-four patients harboring high grade gliomas, treated surgically at the Department of Neurosurgery, Niigata University from April 2018 to August 2020, were included. Patients with high grade gliomas were divided into isocitrate dehydrogenase (IDH)- wildtype and mutant groups, and the presence or absence of VTE and the intensity of PDPN by immunohistochemistry were confirmed. Platelet counts, as well as plasma sCLEC-2 and PDPN were measured in these patients. Furthermore, the levels of sCLEC-2 concentration were divided by the platelet count (C2PAC index) for comparison.

RESULTS

IDH-wildtype glioma patients highly expressed PDPN (P < 0.001) compared to IDH-mutant glioma patients. In total, 9 (20.5 %) patients were diagnosed with VTE during the follow-up period, of which 8 patients harbored IDH-wildtype gliomas, and one patient an IDH-mutant glioma. Mean sCLEC-2 levels and C2PAC index in patients with IDH-wildtype gliomas were significantly higher than that of low or no PDPN expression group, which included patients with IDH-mutant gliomas (P = 0.0004, P = 0.0002). In patients with IDH-wildtype gliomas, the C2PAC index in patients with VTE was significantly higher than in patients without VTE (P = 0.0492). The optimal cutoff point of C2PAC for predicting VTE in IDH-wildtype glioma patients was 3.7 with a sensitivity of 87.5 % and specificity of 51.9 %.

CONCLUSION

Platelet activation is strongly involved in the development of VTE in patients with IDH-wildtype high grade gliomas, and C2PAC index is a potential marker to detect VTE formation after surgery.

Association between IDH mutational status and tumor-associated epilepsy or venous thromboembolism in patients with grade II and III astrocytoma

In previous studies, isocitrate dehydrogenase (IDH) mutations were associated with tumor-associated epilepsy (TAE) and venous thromboembolism (VTE). We examined the relationship between IDH mutations in grade II/III astrocytomas and TAE/VTE according to the 2016 World Health Organization classification. The clinical data of patients with newly diagnosed grade II/III gliomas who were treated at Tohoku University Hospital from January 2010 to December 2018 were reviewed. Associations between TAE or VTE and the clinical/biological characteristics, histology, and IDH1/2 mutational status in patients with grade II/III gliomas were evaluated. Of the initial 137 patients (290 hospitalizations), 117 patients (203 hospitalizations) were included in the TAE group and 124 patients (213 hospitalizations) were included in the VTE group. Seventy-eight patients (66.7%) in the TAE group were diagnosed with astrocytoma and 38/78 (48.3%) presented with TAE. According to the multivariable analysis, the IDH mutational status and male sex were associated independently with an increased risk of TAE (p < 0.05). Eighty-five patients (68.5%) in the VTE group were diagnosed with astrocytoma. VTE was observed in 16/161 (9.9%) hospitalizations. According to the multivariable analysis, age, diffuse astrocytoma histology, and resection were associated independently with an increased risk of VTE. The decision tree analysis showed that TAE was more frequent in younger patients while VTE was more frequent in older patients. This study demonstrated that the IDH mutational status was associated with TAE but not with VTE. Therefore, a future large-scale study is needed to provide sufficient evidence. TAE was more common in young patients, while VTE was more common in the elderly.

Preoperative and intraoperative predictors of deep venous thrombosis in adult patients undergoing craniotomy for brain tumors: A Chinese single-center, retrospective study

PURPOSE

Brain tumor resection by craniotomy is associated with a high risk of deep vein thrombosis (DVT). This study evaluated the incidence and preoperative and intraoperative risk factors for DVT within 30 days of surgery.

METHODS

The analysis included: 1) basic clinical variables (patient age, sex, body mass index [BMI], tumor location, and tumor histology); 2) blood test results before operation, such as leukocytes, platelets, and coagulation parameters; and 3) surgical factors (total amount of blood lost, anesthesia mode, and surgery duration).

RESULTS

Of the 1670 patients, 206 (12.34%) had DVT and nine (0.54%) had both DVT and pulmonary embolism (PE) after surgery. Preoperative and intraoperative factors independently associated with DVT/PE were: older age 46-55 years (odds ratio [OR]: 2.87; 95% confidence interval [CI]: 1.83-4.50; P < 0.001), age 56-65 years (OR: 5.24; 95% CI: 3.27-8.40; P < 0.001), age > 65 years (OR: 6.00; 95% CI: 3.45-10.45; P < 0.001), BMI (OR: 1.03; 95% CI: 1.00-1.05; P = 0.029), activated partial thromboplastin time [APTT] (OR: 0.91; 95% CI: 0.86-0.95; P = 0.000), D-dimer (OR: 1.69; 95% CI: 1.23-2.34; P = 0.001), high-grade glioma (OR: 2.09; 95% CI: 1.28-3.40; P = 0.003), glio-neuronal (OR: 3.30; 95% CI: 1.28-8.47; P = 0.013), craniopharyngioma (OR: 2.16; 95% CI: 1.13-4.10; P = 0.019), and surgery duration (OR: 1.82; 95% CI: 1.27-2.60; P = 0.001).

CONCLUSIONS

Older age, BMI, preoperative APTT, D-dimer, tumor histology, and surgery duration independently increased the risk of developing postoperative DVT/PE. These findings provide prognostic information that will guide therapies aimed at minimizing the development of DVT/PE during hospitalization.

Evaluation of a D-Dimer Protocol for Detection of Venous Thromboembolism

BACKGROUND

The use of venous duplex ultrasonography (VDU) for confirmation of deep venous thrombosis in neurosurgical patients is costly and requires experienced personnel. We evaluated a protocol using D-dimer levels to screen for venous thromboembolism (VTE), defined as deep venous thrombosis and asymptomatic pulmonary embolism.

METHODS

We used a retrospective bioinformatics analysis to identify neurosurgical inpatients who had undergone a protocol assessing the serum D-dimer levels and had undergone a VDU study to evaluate for the presence of VTE from March 2008 through July 2017. The clinical risk factors and D-dimer levels were evaluated for the prediction of VTE.

RESULTS

In the 1918 patient encounters identified, the overall VTE detection rate was 28.7%. Using a receiver operating characteristic curve, an area under the curve of 0.58 was identified for all D-dimer values (P = 0.0001). A D-dimer level of ≥2.5 μg/mL on admission conferred a 30% greater relative risk of VTE (sensitivity, 0.43; specificity, 0.67; positive predictive value, 0.27; negative predictive value, 0.8). A D-dimer value of ≥3.5 μg/mL during hospitalization yielded a 28% greater relative risk of VTE (sensitivity, 0.73; specificity, 0.32; positive predictive value, 0.24; negative predictive value, 0.81). Multivariable logistic regression showed that age, male sex, length of stay, tumor or other neurological disease diagnosis, and D-dimer level ≥3.5 μg/mL during hospitalization were independent predictors of VTE.

CONCLUSIONS

The D-dimer protocol was beneficial in identifying VTE in a heterogeneous group of neurosurgical patients by prompting VDU evaluation for patients with a D-dimer values of ≥3.5 μg/mL during hospitalization. Refinement of this screening model is necessary to improve the identification of VTE in a practical and cost-effective manner.

Podoplanin Expression and IDH-Wildtype Status Predict Venous Thromboembolism in Patients with High-Grade Gliomas in the Early Postoperative Period

OBJECTIVE

Venous thromboembolism (VTE) often is encountered in patients with high-grade gliomas. The underlying mechanisms are unclear, as is the optimal prophylactic protocol. The purpose of the present study was to identify risk factors of VTE and examine the validity of early VTE detection in high-grade gliomas.

METHODS

We reviewed the medical records of 165 patients with newly diagnosed high-grade glioma treated at Niigata University Hospital during the years 2009 to 2016. If the serum D-dimer levels increased to 5.0 μg/mL or more, computed tomography was performed to detect VTE. Furthermore, immunohistochemistry with antibodies against podoplanin was performed on available 101 tumor tissues.

RESULTS

Of the 165 patients, 44 (26.7%) developed VTE. Of the 44 patients, 34 (79.5%) developed VTE within 7 days after surgery. No fatal VTE occurred and major complications secondary to anticoagulation occurred in only 2 (1.2%) patients. On multivariate analysis, lower Karnofsky Performance Scale status, podoplanin expression, and isocitrate dehydrogenase-wildtype status were independently associated with the risk of VTE (P < 0.05).

CONCLUSIONS

We found that most VTEs occurred early in the postoperative period and commonly in patients with lower Karnofsky Performance Scale status and isocitrate dehydrogenase-wildtype gliomas, which expressed podoplanin.

Risk of venous thromboembolism and primary prophylaxis in cancer

Venous thromboembolism (VTE) is a common complication in patients with cancer that causes significant morbidity and mortality. Several patient-, tumour-and treatment-related risk factors for VTE in cancer patients have been identified. An effective and safe thromboprophylaxis in cancer patients at high risk of VTE is desirable. Recently, the identification of potential biomarkers and the development of risk scoring models for prediction of cancer-associated VTE have been published. Whether primary VTE prophylaxis based on risk assessment through these biomarkers and risk prediction models might be useful, is currently not yet known. However, thromboprophylaxis is clearly indicated in high-risk situations. While VTE prophylaxis is recommended in cancer patients undergoing surgery and in hospitalised patients with acute disease, studies in ambulatory cancer patients are still rare and evidence for primary VTE prophylaxis is currently limited. In this review, risk factors associated with VTE in cancer patients and current approaches of thromboprophylaxis in different settings, specifically in ambulatory cancer patients are subjected to a critical evaluation.

Low-molecular-weight heparin and intermittent pneumatic compression for thromboprophylaxis in critical patients

The efficacy and safety of physiotherapeutic prophylaxis for venous thromboembolism in critically ill patients with heparin contraindication remains unclear. In the present study it was hypothesized that physiotherapy prophylaxis with intermittent pneumatic compression (IPC) would be safe and effective for patients unable to receive low-molecular-weight heparin (LMWH). In addition, this study investigated whether a combined therapy of IPC with LMWH would be more effective for the prophylaxis of deep vein thrombosis (DVT) in critical patients. A total of 500 patients were divided into four groups according to the prophylaxis of DVT. The IPC group consisted of 95 patients with heparin contraindication that received IPC treatment; the LMWH group consisted of 185 patients that received an LMWH injection; the LMWH + IPC group consisted of 75 patients that received IPC treatment and LMWH injection; and the control group consisted of 145 patients that received no IPC treatment or injection of LMWH. Each patient was evaluated clinically for development of DVT and the diagnosis was confirmed by Doppler study. Venous thromboembolism was a common complication among the trauma patients with severe injuries. Patients responded positively to the treatment used in the intervention groups. Patients exhibited an improved response to LMWH + ICP compared with IPC or LMWH alone, while no significant difference was detected between the IPC and LMWH groups. These results were applicable to patients that had a Wells score of ≥3; however, no significant differences in DVT incidence were observed among the patients who had a Wells score of <3. In this observational study, LMWH + ICP appeared to be more effective than either treatment alone in treating critically ill trauma patients with severe injuries that are at high risk for VTE and bleeding simultaneously.

D-dimer plasma level: a reliable marker for venous thromboembolism after elective craniotomy

OBJECT

The incidence of deep venous thrombosis (DVT) after craniotomy is reported to be as high as 50%. In outpatients, D-dimer levels of more than 0.5 mg/L indicate venous thromboembolism (VTE, which subsumes DVT and pulmonary embolism [PE]) with a sensitivity of 99.4% and a specificity of 38.2%. However, D-dimer levels are believed to be unreliable in postoperative patients. The authors undertook the present study to test the hypothesis that D-dimer levels would be systematically raised in a postoperative population and to define a feasible threshold for identification of VTE.

METHODS

Doppler ultrasonography of the lower extremity was performed pre- and postoperatively to evaluate for DVT in 101 patients who underwent elective craniotomy. D-dimer levels were assessed preoperatively and on the 3rd, 7th, and 10th days after surgery. Statistical analysis was carried out to define a feasible threshold for D-dimer levels.

RESULTS

D-dimer plasma levels were found to be systematically raised postoperatively, and they differed between patients with and without VTE in a highly significant way. On the 3rd day after surgery, D-dimer levels of more than 2 mg/L indicated VTE with a sensitivity of 95.3% and a specificity of 74.1%, allowing for the definition of a feasible threshold. D-dimer levels of more than 4 mg/L were observed in all patients who had PE during the postoperative period (n = 9). Ventilation time and duration of surgery were identified as highly significant risk factors for the development of VTE.

CONCLUSIONS

Using a threshold of 2 mg/L, D-dimer levels will indicate VTE with a high degree of sensitivity and specificity in patients who have undergone craniotomy. Pulmonary embolism seems to be indicated by even higher D-dimer levels. Given that the development of D-dimer plasma levels in the postoperative period follows a principle that can be predicted and that deviations from it indicate VTE, this principle might be applicable to other types of surgery.

Deep venous thrombosis among disaster shelter inhabitants following the March 2011 earthquake and tsunami in Japan: a descriptive study

Objectives

A retrospective analysis of data collected during subject screening following Japan's March 2011 earthquake and tsunami was performed. We aimed to determine the incidence of deep venous thrombosis (DVT) among screened subjects and to identify risk factors associated with the development of DVT as independent variables.

Methods

Calf ultrasonography was undertaken in 269 subjects living in 21 shelters in Miyagi prefecture during the one-month period immediately following the March 2011 disaster. Information regarding the health and risk factors of subjects was collected by questionnaire and assessment of physical signs.

Results

Of the 269 evacuees screened, 65 (24%) met the criteria for calf DVT. We found lower limb trauma, reduced frequency of urination and sleeping in a vehicle to be independent positive predictors of DVT.

Conclusions

Evacuees had an increased risk of developing DVT, associated with tsunami-related lower limb injury, immobility and dehydration.

Screening strategy using sequential serum D-dimer assay for the detection and prevention of venous thromboembolism after elective brain tumor surgery

OBJECTIVE

Venous thromboembolism (VTE) is a life-threatening complication in neurosurgical patients. This study retrospectively analyzed the effectiveness and safety of a screening strategy for the detection and prevention of VTE in patients undergoing elective brain tumor surgery.

PATIENTS

A total of 419 consecutive patients who underwent brain tumor surgery during 5 years were enrolled. At the midpoint of the study period, screening for VTE was introduced based on measurement of serum D-dimer level on the day after surgery and then once or twice every week. Anticoagulant therapy was started after the diagnosis of VTE. The two groups with (228 patients) and without (191 patients) screening were compared.

RESULTS

Most of the demographic and clinical characteristics were relatively well balanced in the groups. VTE was diagnosed in 23 (5.5%) patients overall; the rate was higher in the screening group (7.0%) than in the non-screening group (3.7%). Although the rate of VTE-related adverse events was lower in the screening group (1.3% vs. 2.6%), the rate of hemorrhagic complications was higher (2.2% vs. 0.5%). Multivariate analysis indicated that malignant histology and preoperative paresis were independent risk factors for the diagnosis of VTE.

CONCLUSIONS

Many VTE patients may not exhibit signs or symptoms, so screening using surrogate markers for VTE (D-dimer) may be useful in the early detection of asymptomatic VTE. However, most distal, deep venous thrombosis in isolation is not life-threatening, so the added efficacy of anticoagulant agents at this stage has to be weighed against the risks of hemorrhagic complications, especially in the early postoperative period.