Silent pulmonary thromboembolism in neurosurgery patients: Report of 2 cases and literature review

[Pulmonary embolism in neurosurgical patients]

Pulmonary embolism (PE) is a serious problem for neurosurgical patients because of high risk of mortality and the need to choose effective and safe anticoagulation.

OBJECTIVE

To analyze the patients with PE after neurosurgical interventions.

MATERIAL AND METHODS

A prospective study was performed at the Burdenko Neurosurgical Center between January 2021 and December 2022. Inclusion criteria were neurosurgical disease and PE.

RESULTS

In accordance with inclusion criteria, we analyzed 14 patients. Mean age was 63 [45.8; 70.0] years. Four patients died. PE was a direct cause of death in 1 case. PE occurred in 5.14±3.68 days after surgery. Anticoagulation was safely implemented in 3 patients with PE on the first day after craniotomy. In a patient with massive PE several hours after craniotomy, anticoagulation resulted hematoma with brain dislocation and death. Thromboextraction and thrombodestruction were used in 2 patients with massive PE and high risk of mortality.

CONCLUSION

Despite low incidence (0.1%), PE is a serious problem in neurosurgical patients due to the risk of intracranial hematoma under effective anticoagulant therapy. In our opinion, endovascular interventions with thromboextraction, thrombodestruction or local fibrinolysis are the safest in the treatment of PE after neurosurgery. Individual approach considering clinical, laboratory data, advantages and disadvantages of a particular anticoagulant drug is required when choosing the tactics of anticoagulation. Further analysis of a larger number of clinical cases is needed to develop the guidelines for the management of neurosurgical patients with PE.

Pulmonary Embolism and Sigmoid Sinus Thrombosis After Translabyrinthine Vestibular Schwannoma Resection: A Retrospective Case Series

OBJECTIVE

To describe the presentation and treatment of patients developing pulmonary embolism following translabyrinthine approach for vestibular schwannoma resection.

METHODS

This was a retrospective case series of patients at 2 academic tertiary medical centers who developed symptomatic pulmonary embolism post-operatively following translabyrinthine approach for vestibular schwannoma resection and were found to have evidence of sigmoid sinus thrombosis.

RESULTS

Three patients were identified to have post-operative pulmonary emboli after translabyrinthine approach for vestibular schwannoma resection with sigmoid sinus or internal jugular vein clots in the absence of lower extremity deep vein thrombosis. Caprini scores for these patients were 5 or lower. All patients underwent CT pulmonary angiography and were confirmed to have pulmonary emboli. Two were promptly anticoagulated with heparin drips and transitioned to long-term oral anticoagulation therapy and 1 had delayed anticoagulation. None of these patients suffered from intracranial hemorrhage post-operatively.

CONCLUSIONS

Patients undergoing translabyrinthine approach for vestibular schwannoma can develop pulmonary embolism from sigmoid sinus entry or thrombosis. No clear guidelines exist for the management of this complication in the setting of recent craniotomy and the risk of intracranial hemorrhage must be considered prior to initiating anticoagulation.