Venous Thromboembolism Anticoagulation Prophylaxis Timing in Patients Undergoing Craniotomy for Tumor

Abstract

BACKGROUND Prophylactic anticoagulation helps prevent postoperative venous thromboembolism (VTE) and time to initiation postcraniotomy has relied on clinical judgment and practice patterns. OBJECTIVE To compare risks of postoperative VTE and hemorrhage among patients undergoing tumor resection with initiation of prophylactic anticoagulation on postoperative day 1 (POD1) vs POD2. METHODS Adult patients undergoing craniotomy for tumor between 2008 and 2018 were retrospectively reviewed. Outcomes were recorded from the Electronic medical record (EMR) including deep vein thrombosis (DVT), pulmonary embolism (PE), and hemorrhage. RESULTS Of a total of 1168 patients undergoing craniotomy, 225 initiated anticoagulation on POD1 and 389 initiated on POD2. Of the 171 glioblastoma (GBM) cases, 64 initiated on POD1 and 107 on POD2. There were 9 DVTs (1.5%), 1 PE (0.20%), overall VTE rate of 1.6%, and 7 hemorrhagic complications (1.10%), 4 being clinically significant. The GBM cohort contained 4 DVTs (2.3%) and 3 hemorrhagic complications (1.80%). There was no increased risk of VTE or hemorrhage with anticoagulation initiated on POD2 compared to POD1 in either cohort. Multivariate analysis in both cohorts did not reveal a significant association between DVT, PE, or hemorrhagic complications with age, body mass index, GBM pathology, or extent of resection. Interestingly, glioma patients older than 70 with subtotal resection had a higher likelihood of suffering intracranial hemorrhage when anticoagulation was started on POD1 (odds ratio 12.98). CONCLUSION Risk of VTE or hemorrhagic complication did not significantly differ with prophylactic anticoagulation started on POD1 vs POD2. Early anticoagulation may certainly be considered in high risk cases; however, 1 group where risk may outweigh benefit is the elderly glioma population receiving a subtotal resection.

A Retrospective Comparative Cohort Study of Craniotomy and Prophylactic Enoxaparin Timing

“…Low molecular weight heparins, such as enoxaparin, have been shown to reduce the risk of developing lower extremity deep venous thrombosis (DVT) without severe risk of ICH [6]. However, there is debate over when to initiate VTE pharmacologic prophylaxis after brain surgery [7][8]. Appropriate timing of prophylactic treatment is crucial to prevention of long-term complications and increased mortality.…”