Perioperative thromboprophylaxis in patients with craniotomy for brain tumours: a systematic review

Abstract

Venous thromboembolism (VTE) events are frequent in neurooncological patients in perioperative period thus increasing mortality and morbidity. The role of prophylaxis has not yet been established with certainty, and in various neurosurgery and intensive care units the practice is inconsistent. A better definition of the risk/cost/benefit ratio of the various methods, both mechanical (intermittent pneumatic compression-IPC, graduated compression stockings-GCS) and pharmacological (unfractionated heparin-UFH or low molecular weight heparin-LMWH), is warranted. We aim to define the optimal prophylactic treatment in the perioperative period in neurooncological patients. A systematic review of the literature was performed in Medline, Embase and Cochrane Library. Thirteen randomized controlled trials (RCTs) were identified, in which physical methods (IPC or GCS) and/or drugs (UFH or LMWHs) were evaluated in perioperative prophylaxis of neurological patients, mostly with brain cancer not treated with anticoagulants for other diseases. The analysis was conducted on a total of 1,932 randomized patients of whom 1,558 had brain tumours. Overall data show a trend of reduction of VTE in patients treated with mechanical methods (IPC or GCS) that should be initiated preoperatively and continued until discharge or longer in case of persistence of risk factors. The addition of enoxaparin starting the day after surgery, significantly reduces clinically manifest VTE, despite an increase in major bleeding events. Further studies are needed to delineate the types of patients with an increase of VTE risk and risk/benefits ratio of physical and pharmacological treatments in the perioperative period.

Venous thromboembolism prophylaxis in cancer patients — guidelines focus on surgical patients

“…Both, intra-cranial surgery and a malignant tumor presence significantly increase the risk of local bleeding complications [14,150,151].…”

“…Studies of limited quality on antithrombotic prophylaxis in the field of cancer neurosurgery indicate that the risk for venous thromboembolism is high when no prophylaxis is administered [150][151][152].…”

“…Available studies on thrombosis prophylaxis in neurosurgery suggest the possibility to reduce the VTE risk effectively by the means of mechanical methods, as well as pharmacological prophylaxis [150][151][152]. However, most of these reports apply to the patients operated not only due to cancer.…”

“…However, most of these reports apply to the patients operated not only due to cancer. Prospective trials on effectiveness and safety of thrombosis prophylaxis in the oncological patient population undergoing neurosurgery are still very rare [150].…”

“…Application of mechanical methods of VTE prophylaxis in neurosurgical patients is a focus of interest, especially for procedures having a high bleeding risk, including neurosurgical oncological procedures [14,150,151]. Apart from early patient mobilization, which is not always possible, mechanical methods of prophylaxis available for this group include intermittent pneumatic compression (IPC), graduated compression stocking, and electric calf muscle stimulation.…”