Incidence and Risk Factors for Venous Thromboembolism Following Craniotomy for Intracranial Tumors: A Cohort Study

Duplex Ultrasound Screening for Deep Venous Thrombosis in Patients Undergoing Craniotomy for Intracranial Tumors: A Single Institutional Series

OBJECTIVE

The frequency of duplex ultrasound screening (DUS) for deep vein thrombosis (DVT) in patients with brain tumors undergoing craniotomy is center-specific. We evaluated clinical conditions that increase the tendency to perform DUS, focusing on tumor type.

METHODS

This is a single-center retrospective analysis to assess the association of intracranial tumor type with DVT as a major decision-making indicator for DUS. A primary analysis investigated the association between tumor pathology and preoperative DVT, and a secondary analysis investigated the development of DVT postoperatively. Confounding factors were defined and included in both analyses.

RESULTS

Among 1478 patients, 751 had preoperative DUS and 35 (5%) had DVT. No significant difference in the odds of preoperative DVT was observed between patients having malignant glioma versus benign tumors (odds ratio [OR; 95% CI]: 1.68 [0.65, 4.35], P = 0.29), or metastatic tumors versus benign tumors (OR: 2.10; 95% CI: 0.75-5.89; P = 0.16). Among patients with negative preoperative DUS, 93 underwent postoperative evaluation and 20 (22%) were diagnosed with postoperative DVT. Malignant glioma or (OR: 1.69; 95% CI: 0.36-7.84; P = 0.50) metastatic tumors (OR: 1.84; 95% CI: 0.29-11.5; P = 0.52) were not associated with postoperative DVT versus benign tumors.

CONCLUSION

Brain tumor pathology may not increase the risk for DVT and may not be a good indicator for the selection of patients for DVT screening with DUS. The incidence of DVT in selective preoperative DUS was similar to studies that performed DUS on all patients. Further studies across multiple institutions are needed to develop criteria for DUS in brain tumor surgery.

Effect of the enhanced recovery after surgery protocol in patients undergoing elective craniotomies: a systematic review and meta-analysis

Enhanced recovery after surgery protocol (ERASP) improves postoperative outcomes. However, its implementation in neurosurgery remains under explored, resulting in the absence of standard evidence-based guidelines. Thus, we compared the outcomes of ERASP and conventional perioperative care (CPC) in patients undergoing elective craniotomy for various intracranial pathologies. This systematic review and meta-analysis involved the search of PubMed, Cochrane Library, and Google Scholar until December 4, 2024. The primary outcomes were total and postoperative length of stay (LOS). Secondary outcomes included hospitalization cost, pain, analgesic use, Karnofsky performance status (KPS) score, postoperative nausea and vomiting (PONV), postoperative complications, 30-days readmission and reoperation, and mortality. A total of 15 studies, including randomized controlled trials (n = 9) as well as prospective and retrospective studies (each n = 3) were included. Compared to CPC, ERASP significantly reduced total LOS (MD -3.32, 95%CI -3.66 to -2.98; P < 0.0001, I2 = 34%), postoperative LOS (MD -2.80, 95%CI -3.82 to -1.79; P < 0.0001, I2 = 90%), hospitalization cost (MD -$1044, 95%CI -$1289 to -$800; P < 0.0001, I2 = 47%), postoperative pain (MD -1.55, 95%CI -1.92 to -1.19; P < 0.0001, I2 = 83%), analgesic use (OR 0.56, 95%CI 0.40 to 0.80; P = 0.001, I2 = 0%), KPS score (MD 6.68, 95%CI 0.15 to 13.21; P = 0.045, I2 = 93%), respiratory complications (OR 0.28, 95%CI 0.13 to 0.58; P = 0.001, I2 = 0%), and PONV (OR 0.39, 95%CI 0.27 to 0.57; P < 0.0001, I2 = 0%). While ERASP and CPC were comparable regarding other outcome measures. Thus, in elective craniotomy, ERASP shortens total and postoperative LOS, decreases hospitalization costs, improves functional recovery, decreases pain and analgesic use, with reduced incidence of PONV and respiratory complications.

Three-Month Incidence of Venous Thromboembolism in Patients Who Underwent Neurological Surgeries

Background/Objectives: The incidences of venous thromboembolism (VTE) in patients undergoing neurological surgeries vary. The objectives were to assess the incidence and risk factors of VTE, bleeding and all-cause mortality in patients undergoing neurological surgery. Methods: This retrospective cohort study was conducted at a single center, a university-based hospital in Thailand. Inclusion criteria comprised patients aged 15 years or older who were admitted for elective or emergency neurosurgery. Patients with preoperative VTE diagnosed within three months or a history of anticoagulant use were excluded. Outcomes measured included the 90-day incidences of VTE, any bleeding, major bleeding, and mortality. Results: Between January 2021 and December 2022, a total of 626 patients were included. The mean age was 50.21 ± 17.37 years, and 55.27% were males. Thromboprophylaxis was administered to 86 patients (13.74%, 95% CI 11.14-16.69). Fourteen patients were confirmed to have symptomatic VTE, resulting in an incidence of 2.24%, with a 95% confidence interval (CI) of 1.23-3.72. Patients aged ≥75 years (HR 4.53; 95% CI 1.25-16.38; p = 0.021), those with cancer (HR 8.51; 95% CI 2.95-24.60, p <0.001), and those experiencing postoperative paraparesis/paralysis (HR 3.26; 95% CI 1.12-9.45; p = 0.030) were associated with an increased risk of postoperative VTE. Fifty-three patients (8.47%, 95% CI 6.41-10.93) experienced any bleeding, with 23 patients (3.67%, 95% CI 2.34-5.46) having major bleeding. The incidence of postoperative mortality was 6.55%, with a 95% CI of 4.74-8.78. Conclusions: This study revealed that elderly patients, those with cancer or those experiencing postoperative paraparesis/paralysis were at higher risk of VTE. These patients were likely to benefit from VTE prophylaxis.

Influence of postoperative D-dimer evaluation and intraoperative use of intermittent pneumatic vein compression (IPC) on detection and development of perioperative venous thromboembolism in brain tumor surgery

BACKGROUND OBJECTIVE

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common complication in craniotomy patients and is associated with increased morbidity and mortality. The duration of surgery is a known risk factor. Other factors such as positioning and tumor entity have hardly been investigated or are controversial. In two pilot studies, the determination of plasma D-dimer concentration led to a high detection rate of DVT, while the use of intermittent pneumatic venous compression (IPC) drastically reduced the incidence of VTE. In the present study we investigated the efficacy of the two approaches, either alone or in combination, in a large patient cohort.

METHODS

1759 patients who underwent elective craniotomy between 2009 and 2023 were retrospectively analyzed. The staggered use of D-dimer determination and intraoperative use of IPC resulted in 3 groups: Group 1: no procedure; Group 2: D-dimer evaluation; Group 3: IPC and D-dimer evaluation. If the D-dimer level was ≥ 2 mg/l (Fibrinogen equivalent units; FEU), venous ultrasound was performed. Age, gender, tumor entity, duration and extent of surgery, patient positioning, type of VTE were also recorded and analyzed.

RESULTS

The introduction of postoperative D-dimer evaluation increased the rate of detection of thrombosis from 1.7% in group 1 to 22.6% in group 2. The addition of IPC reduced the rate of thrombosis to 4.4%. Age, gender and patient positioning did not affect the rate of VTE. We were able to confirm the duration of surgery as an individual risk factor and showed that WHO grade 4 tumors and metastasis have an increased VTE risk.

CONCLUSIONS

If D-Dimer levels are not analyzed routinely about 20% of craniotomy patients suffer from a clinically silent thrombosis. Each with the risk of fate PE. Intraoperative use of IPC during craniotomy dramatically reduces the risk of VTE.

Prevalence, characteristics, and risk factors of venous thromboembolism in patients with brain tumor undergoing craniotomy: a meta-analysis

BACKGROUND

Brain tumor patients undergoing craniotomy are significantly associated with the development of venous thromboembolism (VTE), while the contributing factors remains controversial. Our study aimed to investigate the prevalence and risk factors for VTE in postoperational brain tumor patients.

METHODS

We searched the PubMed, Embase, Web of Science, Medline, and Cochrane Library databases from their inception to July 2023. Article selection, data extraction, and study quality assessment were performed independently by two reviewers. Publication bias was assessed using Egger's and Begg's tests. Stata 15.0 software was used for data analysis.

RESULTS

A total of 25 studies were considered, with a total of 49,620 brain tumor individuals. The pooled prevalence of VTE during hospitalization in postoperational brain tumor patients was 9% [95% CI: (0.08, 0.10)]. Moreover, our results demonstrated that patients with VTE were older than those without VTE [mean difference [MD] = 8.14, 95% CI: (4.97, 11.30)]. The following variables were significantly associated with VTE: prior history of VTE [OR = 7.81, 95% CI: (3.62, 16.88)], congestive heart failure [OR = 2.33, 95% CI: (1.08-5.05)], diabetes [OR = 1.87, 95% CI: (1.12-3.10)], hypertension [OR = 1.27, 95% CI: (1.07-1.50)], steroid use [OR = 1.63, 95% CI: (1.41, 1.88)], high white blood cells counts [MD = 0.32, 95% CI: (0.01, 0.63)], and high fibrinogen levels [MD = 0.19, 95% CI: (0.08, 0.30)].

CONCLUSION

This meta-analysis identified risk factors for postoperational VTE in patients with brain tumor, which can serve as a theoretical foundation for medical staff to manage and treat VTE.

TRIAL REGISTRATION

CRD42023357459.

Safety and timing of early therapeutic anticoagulation therapy after craniotomy

Background

To date, there are few guidelines and studies to guide the timing of initiation of therapeutic anticoagulation (AC) after craniotomy. The goal of this study was to assess the timing, safety, and outcomes of patients following the administration of therapeutic AC after craniotomy.

Methods

A retrospective case-control study was performed evaluating all craniotomy patients from August 2017 to July 2021. Cases were selected if they received therapeutic AC within ten days of craniotomy. Nineteen out of 1013 craniotomy patients met the inclusion criteria. Indications for therapeutic AC were diverse, including deep venous thrombosis, pulmonary embolism, dural venous sinus thrombosis, mechanical heart valve, and left ventricular thrombus.

Results

The mean and median time to therapeutic AC were 5.35 and 5 days, respectively. Three patients developed intracerebral hemorrhage (ICH) that was stable on repeat imaging and did not require any surgical intervention or result in new neurologic deficits. There was no significant association between therapeutic AC and postoperative ICH (P = 0.067).

Conclusion

This study demonstrated that the initiation of therapeutic AC in postoperative craniotomy patients from postoperative days 2 to 10 did not result in any major complications. A prospective study is warranted to clarify the indications and safety of therapeutic AC after craniotomy.

Thromboembolic prophylaxis in neurosurgical practice: a systematic review

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Retrospective Analysis of the Postoperative Effect of Intraoperative Hypothermia on Deep Vein Thrombosis After Intracranial Tumor Resection

BACKGROUND

Deep venous thrombosis (DVT) is a common clinical vascular disease, and post-thrombotic syndrome is usually the complication of patients. This study was to explore the relationship between intraoperative hypothermia and DVT.

METHODS

Patients who were clinically diagnosed with intracranial tumors and underwent tumors resection from January 2019 to March 2021 were studied and divided into the DVT and non-DVT group. Prothrombin time, activated partial prothrombin time (ATPP), thrombin time, plasma fibrinogen, and venous flow velocity of both lower limbs were measured to observe DVT and the incidence of DVT. Univariate and multivariate logistic regression analyses were used to investigate the correlation between intraoperative hypothermia and DVT, and to analyze the DVT-related risk factors.

RESULTS

A total of 462 patients were analyzed, of whom 231 patients were allocated to the DVT group and 231 were in the non-DVT group. Within the DVT group, 156 patients (33.8%) experienced intraoperative hypothermia. The risk factors that were significantly correlated with DVT were age, sex, operation time, ATPP value, and intraoperative hypothermia. The decreased ATPP value was found to be significantly associated with the increased incidence of DVT, and older ages (>45 years) were highly associated with DVT. Low body temperature before operation and intraoperative hypothermia were statistically significant as well. In addition, significant association was also displayed between the patient's operation time (>350 minutes) and DVT.

CONCLUSION

Patients who underwent intracranial tumor resection experience a high incidence of DVT, and patients with intraoperative hypothermia are at greater risk of DVT.

Analysis of the Factors Related to Intracranial Infection after Brain Tumor Surgery

In order to explore the factors related to intracranial infection after brain tumor surgery, a retrospective analysis is conducted in this study. According to the patients with intracranial infection after brain tumor surgery in our hospital from January 2020 to October 2020, clinical data are divided into different groups and some indicators are put into the multiple regression model for multivariate analysis. The factors related to intracranial infection after brain tumor surgery are analyzed, and the clinical effect of a detailed management plan based on the abovementioned risk factors to prevent intracranial infection in patients after brain tumor surgery is observed. Multiple regression models demonstrate that complicated underlying diseases, operation time, and intraoperative blood loss are independent risk factors for postoperative intracranial infection.

Predictive risk factors for venous thromboembolism in neurosurgical patients: A retrospective analysis single center cohort study

Background

Venous thromboembolism (VTE) has a major effect on morbidity and mortality in neurosurgical patients. However, identifying risk factors that may be useful in practice is a challenge. The purpose of this study was to investigate the incidence and determine the predictors of VTE in patients undergoing neurosurgery.

Materials and methods

This retrospective, single-center cohort study was conducted on adult patients admitted to a private hospital for a primary elective neurosurgical procedure between January 2015 and December 2020. Univariate analysis was used to examine clinical factors, and multivariable regression analysis was used to identify predictors of VTE. The area under the receiver-operating characteristic (AUROC) curve demonstrated the fitting model and discrimination power.

Results

A total of 350 patients who underwent neurological surgery were identified. There were 26 patients (7.4%) with VTE. The final predictors were found to be statistically significant in the multivariate binary logistic regression analysis, including non-Asian populations (p value < 0.001, odds ratio [OR]: 6.11, 95% confidence interval [CI] = 2.20–16.89), lack of postoperative ambulation (p value = 0.009, OR: 9.25, 95% CI = 1.17–48.83), and septic shock complication (p value = 0.001, OR: 5.36, 95% CI = 1.46–19.62). The AUROC was 0.708 (95% CI 0.61–0.80).

Conclusion

Although the incidence of VTE in patients receiving neurosurgery is minimal, it is also higher in non-Asian patients, those who lack of postoperative ambulation, and patients with septic shock complications. This approach may be useful to predict thromboembolism in neurosurgical patients. External validation of the prognostic model requires more investigation.

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Venous thromboembolism (VTE) complications can be a major cause of morbidity and even death in neurosurgical patients.

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The standard therapy for the appropriate prophylaxis remains unclear.

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Whether or not to use pharmacological prophylaxis is determined by a higher-risk category of individuals.

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Based on information from risk factors, it may be a benefit guide for proper VTE prophylaxis.

Impact of Diabetes Mellitus on Adverse Outcomes After Meningioma Surgery

OBJECTIVE

We sought to investigate the association between diabetes mellitus and incidence of adverse outcomes in patients who underwent meningioma surgery.

METHODS

The 2012-2014 National Inpatient Sample database was used. Prolonged length of stay was indicated by values greater than the 90th percentile of the sample. The Fisher exact test and analysis of variance were used to compare demographics, hospital characteristics, comorbidity, and complications among race cohorts. Logistic regression was used to analyze the independent effect of diabetes on adverse outcomes.

RESULTS

After selecting for patients with primary diagnosis of meningioma who underwent a resection procedure, 7745 individuals were identified and divided into diabetic (n = 1518) and nondiabetic (n = 6227) cohorts. Demographics, hospital characteristics, and comorbidities were significantly different among the 2 cohorts. Average length of stay was longer in diabetic patients (8.15 vs. 6.04 days, P < 0.001), and total charges were higher in diabetic patients ($139,462.66 vs. $123,250.71, P < 0.001). Multivariate regression indicated diabetic patients have higher odds of experiencing a complication (odds ratio [OR] 1.442, 95% confidence interval [CI] 1.255-1.656, P < 0.001) and in-hospital mortality (OR 1.672, 95% CI 1.034-2.705, P = 0.036) after meningioma surgery. Analysis of individual postoperative complications revealed that diabetic patients experienced increased odds of pulmonary (OR 1.501, 95% CI 1.209-1.864, P < 0.001), neurologic (OR 1.690, 95% CI 1.383-2.065, P < 0.001), and urinary/renal complications (OR 2.618, 95% CI 1.933-3.545, P < 0.001). In addition, diabetic patients were more likely to have a prolonged length of stay (OR 1.694, 95% CI 1.389-2.065, P < 0.001).

CONCLUSIONS

Diabetes is an important factor associated with complications after meningioma surgery. Preventative measures must be taken to optimize postoperative outcomes in these patients.