Disseminating clot burden post- craniotomy: The difficult balancing act of clot versus haemorrhage post-neurosurgery

Abstract

Venous thromboembolism (VTE) is the most common complication following craniotomy for neoplastic disease. Its occurrence is associated with a significant morbidity and mortality, and balancing the risks for the subsequent development of VTE versus intracranial haemorrhage (ICH) can lead to difficult management decisions for treating clinicians. We present a case of VTE following craniotomy for meningioma complicated by ICH in the presence of a disseminating clot burden that included pulmonary, intra-cardiac and paradoxical arterial embolic sequelae. Management strategies incorporated pharmacological, radiological and surgical methods. We discuss the evidence for VTE prevention and treatment, as well as the role of inferior vena cava filters and thrombectomy. We finally highlight the use of desmopressin as a potential risk factor for VTE, and encourage the need for an individualised approach to peri-operative risk stratification in the neurosurgical intensive care population.

Keywords

Anticoagulation - inferior vena cava filter - neurosurgical intensive care - thrombectomy - venous thromboembolism

• REFERENCES

• 1 Kimmell KT, Walter KA. Risk factors for venous thromboembolism in patients undergoing craniotomy for neoplastic disease. J Neurooncol 2014; 120: 567-73
• 2 Smith TR, Nanney 3^rd AD, Lall RR, Graham RB, McClendon Jr. J, Lall RR. et al. Development of venous thromboembolism (VTE) in patients undergoing surgery for brain tumors: Results from a single center over a 10 year period. J Clin Neurosci 2015; 22: 519-25
• 3 Hamilton MG, Hull RD, Pineo GF. Venous thromboembolism in neurosurgery and neurology patients: A review. Neurosurgery 1994; 34: 280-96
• 4 Marras LC, Geerts WH, Perry JR. The risk of venous thromboembolism is increased throughout the course of malignant glioma: An evidence-based review. Cancer 2000; 89: 640-6
• 5 Khaldi A, Helo N, Schneck MJ, Origitano TC. Venous thromboembolism: Deep venous thrombosis and pulmonary embolism in a neurosurgical population. J Neurosurg 2011; 114: 40-6
• 6 Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg 1999; 86: 992-1004
• 7 Comerota AJ, Chouhan V, Harada RN, Sun L, Hosking J, Veermansunemi R. et al. The fibrinolytic effects of intermittent pneumatic compression: Mechanism of enhanced fibrinolysis. Ann Surg 1997; 226: 306-13
• 8 Skillman JJ, Collins RE, Coe NP, Goldstein BS, Shapiro RM, Zervas NT. et al. Prevention of deep vein thrombosis in neurosurgical patients: A controlled, randomized trial of external pneumatic compression boots. Surgery 1978; 83: 354-8
• 9 Morris RJ, Woodcock JP. Intermittent pneumatic compression or graduated compression stockings for deep vein thrombosis prophylaxis? A systematic review of direct clinical comparisons. Ann Surg 2010; 251: 393-6
• 10 Turpie AG, Hirsh J, Gent M, Julian D, Johnson J. Prevention of deep vein thrombosis in potential neurosurgical patients. A randomized trial comparing graduated compression stockings alone or graduated compression stockings plus intermittent pneumatic compression with control. Arch Intern Med 1989; 149: 679-81
• 11 Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA. et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9^th ed: American College of Chest Physicians Evidence-based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) Suppl e227S-77S
• 12 CLOTS (Clots in Legs or sTockings after Stroke) Trial Collaboration. Thigh-length versus below-knee stockings for deep venous thrombosis prophylaxis after stroke: A randomized trial. Ann Intern Med 2010; 153: 553-62
• 13 Sajid MS, Desai M, Morris RW, Hamilton G. Knee length versus thigh length graduated compression stockings for prevention of deep vein thrombosis in postoperative surgical patients. Cochrane Database Syst Rev 2012; 5: CD007162
• 14 Frisius J, Ebeling M, Karst M, Fahlbusch R, Schedel I, Gerganov V. et al. Prevention of venous thromboembolic complications with and without intermittent pneumatic compression in neurosurgical cranial procedures using intraoperative magnetic resonance imaging. A retrospective analysis. Clin Neurol Neurosurg 2015; 133: 46-54
• 15 Partsch H. Ambulation and compression after deep vein thrombosis: Dispelling myths. Semin Vasc Surg 2005; 18: 148-52
• 16 Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: A meta-analysis. Arch Intern Med 2000; 160: 2327-32
• 17 Collen JF, Jackson JL, Shorr AF, Moores LK. Prevention of venous thromboembolism in neurosurgery: A metaanalysis. Chest 2008; 134: 237-49
• 18 Dickinson LD, Miller LD, Patel CP, Gupta SK. Enoxaparin increases the incidence of postoperative intracranial hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in patients with brain tumors. Neurosurgery 1998; 43: 1074-81
• 19 Kalfas IH, Little JR. Postoperative hemorrhage: A survey of 4992 intracranial procedures. Neurosurgery 1988; 23: 343-7
• 20 Scheller C, Rachinger J, Strauss C, Alfieri A, Prell J, Koman G. Therapeutic anticoagulation after craniotomies: Is the risk for secondary hemorrhage overestimated?. J Neurol Surg A Cent Eur Neurosurg 2014; 75: 2-6
• 21 Cage TA, Lamborn KR, Ware ML, Frankfurt A, Chakalian L, Berger MS. et al. Adjuvant enoxaparin therapy may decrease the incidence of postoperative thrombotic events though does not increase the incidence of postoperative intracranial hemorrhage in patients with meningiomas. J Neurooncol 2009; 93: 151-6
• 22 Rosner MK, Kuklo TR, Tawk R. et al. Prophylactic placement of an inferior vena cava filter in high-risk patients undergoing spinal reconstruction. Neurosurg Focus 2004; 17 (04) E6
• 23 Davies MG, Hart JP, El-Sayed HF. Efficacy of prophylactic inferior vena caval filters in prevention of pulmonary embolism in the absence of deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2016; 4: 127-30.e1
• 24 Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P. et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med 1998; 338: 409-15
• 25 Mismetti P, Laporte S, Pellerin O, Ennezat PV, Couturaud F, Elias A. et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs. anticoagulation alone on risk of recurrent pulmonary embolism: A randomized clinical trial. JAMA 2015; 313: 1627-35
• 26 NICE Guidelines [CG144]. Venous Thromboembolic Diseases: Diagnosis, Management and Thrombophilia Testing. 2012 Available from: http://www.nice.org.uk/guidance/CG144 [Last accessed on 2015 Nov 25].
• 27 Kuo WT, Gould MK, Louie JD, Rosenberg JK, Sze DY, Hofmann LV. Catheter-directed therapy for the treatment of massive pulmonary embolism: Systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol 2009; 20: 1431-40
• 28 Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ. et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9^th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) Suppl e419S-94S
• 29 Naidech AM, Maas MB, Levasseur-Franklin KE, Liotta EM, Guth JC, Berman M. et al. Desmopressin improves platelet activity in acute intracerebral hemorrhage. Stroke 2014; 45: 2451-3
• 30 Kyrle PA, Minar E, Hirschl M, Bialonczyk C, Stain M, Schneider B. et al. High plasma levels of factor VIII and the risk of recurrent venous thromboembolism. N Engl J Med 2000; 343: 457-62