Diffuse intravascular coagulation associated with brain tumor surgery in children

Hematologic Emergencies in the Postoperative Neurointensive Care Unit Setting: Illustrative Case Series and Differential Diagnosis

OBJECTIVES

Investigating the development of acute thrombocytopenia, differential etiologies, and potentially the rare manifestation of disseminated intravascular coagulation after brain tumor resection of primary and secondary malignancies.

MATERIALS AND METHODS

We performed a retrospective review of a case series of post-operative neurosurgical patients which developed thrombocytopenia. We applied National Library of Medicine search engine methodology using the terms disseminated intravascular coagulation and brain tumors.

RESULTS

We report clinical, radiographic, and laboratory data of four Neurointensive care unit patients that developed thrombocytopenia, three with disseminated intravascular coagulation after craniotomy, and one with heparin-induced thrombocytopenia masquerading as low grade disseminated intravascular coagulation. All four patients presented with cranial lesions and underwent neurosurgical resection. Underlying disorders included: high grade glioma, stage IV lung cancer with metastases, and meningioma. One patient survived and was able to recover after several days of hospitalization, while another patient was discharged to hospice. Search results illustrated that disseminated intravascular coagulation in the presence of glioblastoma multiforme is rare (only four patients) and may be due to a release of coagulation factors like tissue plasminogen activator, treated with antifibrinolytic agents. Searching the terms disseminated intravascular coagulation and brain tumors in the National Library of Medicine search engine yielded 116 results; eight were relevant to our study.

CONCLUSIONS

Correlation of thrombocytopenia after neurosurgery for glioblastoma multiforme and disseminated intravascular coagulation is rare. It is extremely challenging to manage these patients with concomitant deep vein thrombosis/pulmonary embolism and intracranial bleeding. Heparin-induced thrombocytopenia is common yet possesses a different hematological coagulation profile and has more pharmacologic options. Neurointensive care unit teams should recognize intraoperative and post-operative disseminated intravascular coagulation cases, and heparin-induced thrombocytopenia in the differential of post-operative thrombocytopenia with specific pharmacologic interventions.

Disseminated Intravascular Coagulation During Resection of a Meningioma: Case Report

BACKGROUND AND IMPORTANCE:

Disseminated intravascular coagulation is a relatively common complication in patients with trauma, sepsis, obstetric calamities, and certain malignancies. We report a rare case of DIC after embolization and surgery for a large meningioma. We also review the literature on coagulopathy during brain tumor surgery as well as the diagnosis and treatment of this complication.

CLINICAL PRESENTATION:

A 62-year-old woman presented with a 3-week history of aphasia, difficulty with handwriting, personality change, and right-sided weakness. Magnetic resonance imaging demonstrated a 6.3 × 5.4-cm multilobe and avidly enhancing mass within the left frontal region. The patient underwent preoperative transcatheter Onyx embolization of the tumor, followed immediately by craniotomy for resection of the tumor. Surgery was complicated by coagulopathy leading to substantial blood loss. The diagnosis of disseminated intravascular coagulation was established by intraoperative thromboelastography, after which the patient was treated with replacement therapy, Amicar, and modest hypotension. One year after surgery, the patient had fully recovered and had no focal neurological deficit.

CONCLUSION:

This case report adds to the few reported cases of disseminated intravascular coagulation as a complication of brain tumor surgery. This patient's successful outcome may be attributed to timely recognition of the condition and effective, prompt treatment.

Disseminated intravascular coagulation in a patient undergoing removal of metastatic brain tumor

The authors present a case of 68-year-old woman who underwent resection of a metastatic adenocarcinoma in the left parietooccipital area. The intraoperative course was uneventful; however, after closure of the scalp incision, increased bleeding from the suture line was noted. A computerized tomography scan that was performed immediately after operation revealed acute epidural hemorrhage with mass effect under the bone flap. The patient developed disseminated intravascular coagulation and immediate re-exploration was performed. This patient was successfully treated owing to early recognition of the condition and immediate treatment with transfusion. Neurosurgeons should be alert that hypercoagulabe state is common in cancer patients and consumptive coagulopathy can occur after resection of metastatic brain tumor.

Critically ill cancer patients are not consistently hypercoagulable after craniotomy

INTRODUCTION

Recent reports using thrombelastography have suggested that neurosurgical patients develop a hypercoagulable state in the postoperative period. Since venous thromboembolism is a potentially life threatening complication in these patients, we studied a similar population in our institution.

METHODS

We conducted a prospective pilot study to evaluate postoperative coagulation changes in critically ill cancer patients after craniotomy. Data collected included demographics, diagnoses, severity of illness, all hematological information (coagulation tests included conventional and TEG), therapies, and complications. Analysis included descriptive statistics, and multivariate regression analysis.

RESULTS

Eleven patients were included in the study. Mean age was 52 +/- 17 years, BMI 28 +/- 6.5, APACHE II and SOFA scores were 11.18 +/- 5.0 and 3.82 +/- 1.6 respectively. The Coagulation Index (CI), which is derived from the measured values of R, K, MA, and alpha angle was 1.22 +/- 3.5, R 4.2 +/- 1.6, K 2.0 +/- 2.1, MA 60.78 +/- 5.97, and alpha angle 66.88 +/- 14.9; while the Thrombodynamic Potential Index (TPI), which is derived from the measured values of K and MA only was 32.48 +/- 21. The CI correlated significantly with R, K, alpha angle, MA, TMA, TPI, PMA, E, A30 and A60 but not with the PTT, INR, or SOFA and APACHE II scores. One patient was hypocoagulable by CI and TPI values; in contrast, nine patients were hypercoagulable by TPI but only one by CI. There were no cases of VTE.

CONCLUSIONS

Hypercoagulability as defined by the CI was not a common finding in this study. Although the TPI indicated hypercoagulability in a large number of patients, we do not believe it is a good tool to assess the patient's clotting status or predictor of thrombosis because in contrast to the CI, it does not take into account the enzymatic portions of the clotting cascade. A larger TEG study is warranted to determine the clinical significance of these changes in this and other populations.

Massive blood transfusion in choroid plexus tumor surgery: 10-years' experience

STUDY OBJECTIVE

To describe our 10 years of experience with childhood choroid plexus tumors (CPTs).

DESIGN

Retrospective chart analysis.

SETTING

Operating room and pediatric intensive care unit (PICU) of a university hospital.

PATIENTS

18 infants and children undergoing CPT surgery from 1995 to 2004, 11 of whom were younger than 12 months.

MEASUREMENTS

Perioperative hematologic and coagulation data were measured as well as estimated red cell volume variations (as a reliable index of blood loss) in the perioperative period, together with coagulation parameters.

RESULTS

Greater blood loss was recorded in the infant group vs older children (percentage of estimated red cell volume loss, 1.31 +/- 1.79% vs 0.20 +/- 0.17% [P < 0.01] and 1.50 +/- 1.86% vs 0.29 +/- 0.21% [P < 0.01] on PICU admission and after 72 hours, respectively). Platelet count decrease was similarly noted (51.60 +/- 28.06 vs 27.57 +/- 11.98, P < 0.05, as percentage of preoperative count). Patients operated on in the neonatal period showed the highest blood loss and related coagulation impairment.

CONCLUSION

Younger CPT surgery patients present an increased risk versus their older counterparts of massive bleeding resulting in hemodynamic instability and coagulative impairment.

Anesthesiological and intensive care considerations in children undergoing extensive cerebral excision procedure for congenital epileptogenic lesions

INTRODUCTION

Epilepsy is a relatively common condition in childhood with a generally favorable prognosis of the affected population. Nevertheless, a significant minority of the treated children do not respond to the medical treatment so that surgical treatment is necessary. While minor surgical procedures have a negligible incidence of mortality, major ones may carry a significant risk of perioperative complications. The leading cause of mortality is represented by hemorrhagic derangements after high intraoperative and postoperative blood loss, mostly in very young patients. Therefore, restoration of euvolemia, detection and correction of related bleeding disorders represent the major concern for pediatric neuroanesthesiologists and intensivists throughout the perioperative period. The present report is focused on the anesthesia and intensive care management of the surgical epileptic patient.

CONCLUSION

Authors recommend that these high-risk procedures should be performed in highly experienced centers where pediatric neurosurgery is performed daily.