Safety and timing of early therapeutic anticoagulation therapy after craniotomy

Abstract

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.

Keywords: Anticoagulation therapy; Craniotomy; Intracranial hemorrhage; Mechanical heart valves; Venous thromboembolism.

Figure 1:

Proposed therapeutic AC algorithm after craniotomy *As determined by consultation with cardiology with features to include left atrial appendage thrombus, left atrial spontaneous echocardiographic contrast, and LV ejection fraction <40%. ^†Based on institutional and departmental interpretation of common heparin nomograms. AC: Anticoagulation, AF: Atrial fibrillation, DVST: Dural venous sinus thrombosis, ICH: Intracerebral hemorrhage, IVC: Inferior vena cava, LV: Left ventricle, MI: Myocardial infarction, PPX: Prophylaxis. VTE: Venous thromboembolism.

Supplemental Figure 1:

Postoperative intracranial hemorrhage after therapeutic AC Patient 6 in (a) suffered a 16 mL ICH in the resection bed of her right cerebellar metastasis. Patient 15 in (b) developed a 35 mL ICH with intraventricular hemorrhage in the context of bifrontal contusions and bifrontal DC after TBI. Patient 17 in (c) had a minimal right tentorial subdural hematoma after leaving DC for TBI. AC: Anticoagulation, DC: Decompressive craniectomy, ICH: Intracerebral hemorrhage, TBI: Traumatic brain injury.