Prevention of venous thromboembolic complications with and without intermittent pneumatic compression in neurosurgical cranial procedures using intraoperative magnetic resonance imaging. A retrospective analysis
Introduction
Deep venous thromboembolism is reported to be the most common adverse event after intracranial neoplasm surgery ranging from 3% to 26% [1]. In adults with malignant gliomas the reported incidence of venous thromboembolism was as high as 72% and generally accepted as 20–30% [2]. Risk factors in malignant gliomas were reported to be age greater than 75, Glioblastoma tumor subtype, subtotal resection compared to total resection, glioma size greater than 5 cm, intraluminal thrombosis in the tumor pathological specimen, A and AB blood type, steroid therapy, chemotherapy, radiation, as well as limb paresis [2]. Other authors found no correlation between tumoral intravascular thrombi in histological specimen and the incidence of deep venous thromboembolism [3]. A reason for the high incidence of deep venous thromboembolism in high-grade glioma might be related to activation of the coagulation cascade by a variety of complex interactions, including tumor hypoxia, upregulation of VEGR expression and increases of tissue factors [4]. Concerning the neurosurgical factor, the risk of developing thromboembolism was found to be higher in the first 2 months after surgery [5]. In the first month after surgery only 27% of venous thromboembolic complications are diagnosed [6].
Prophylactic techniques for deep venous thromboembolism had been widely demonstrated and confirmed [7], but adherence remains unstudied [1].
While the use of image guidance, intraoperative functional mapping and real-time intraoperative MRI guidance can allow surgeons to maximize the resection and preserving function, the second most frequent adverse effect with 0–20% [1]. On the other hand these procedures are time consuming and might lead to a higher risk of thromboembolic events.
To evaluate the introduction of intraoperative and postoperative pneumatic compression additionally to the use of compression stockings, low molecular weight heparin-LMWH and early mobilization, a retrospective study in cranial neurosurgery using intraoperative MRI was performed.
Section snippets
Materials and methods/case material
A retrospective analysis of 207 neurosurgical patients using intraoperative MRI (Espree, Siemens, Germany) was performed. For the prevention of venous thromboembolism in every patient graduated compression stockings (GCS) prior to surgery and low molecular weight heparin-LMWH 1 or 2 days after surgery, depending on the postoperative CT-scan, was used.
One hundred sixty-eight (81.2%) patients received low molecular weight heparin-LMWH 1 day after surgery, 32 (15.5%) patients received low
Age
The mean age of the 15 patients with thrombotic events was 44.3 ± 3.8 with a range of 17–67 years. The mean age of the 192 patients without thrombotic events was 42.5 ± 1.2 with a range of 2–76 years
The mean age of all treated patients was 42.6 ± 1.1 (mean ± SE) with a range of 2–76 years. The mean age of the four patients with pulmonary embolism was 55.5 ± 3.9 with a range of 50–67 years. The mean age of the 203 patients without pulmonary embolism was 42.4 ± 1.2 with a range of 2–76 years.
The differences
Comparison with previous studies (see Table 1)
Only four male patients developed pulmonary embolism in our study group, while thrombotic events were distributed nearly equally among male and female patients. This has not been reported before and might be attributed to the small amount – only four – of patients with pulmonary embolism. Compared with previous similar studies [8], but without the use of intraoperative MRI, the rate of occurrence of thrombotic complications with 8.5% in female and 6.4% in male is more than twofold higher than
Conclusions
This study demonstrates the benefit of intraoperative and postoperative pneumatic compression with a significant risk reduction for the development of thromboembolic complications. OR-time is another risk factor that attributes to a significant risk for the development of thromboembolic complications. Thus, efforts should be undertaken to reduce OR-time, even with the use of intraoperative MRI, mapping of functional areas, cortical stimulation and navigation, though the use of intraoperative
Disclosure
No conflicts of interest.
Acknowledgment
We thank Friederike Mühler and Dana Neumann, technical radiological assistants for documentation.
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