Table 1-
Risk Factors (Most common risk factors in red)
| Article | Number of patients, type of study | Risk factors |
|---|---|---|
| Parmontree et al, 2022 | 350 neurosurgical patients, single centre | Lack of postoperative ambulation Non-Asian ethnicity Septic shock complication |
| Buchanan et al, 2019 | 89,450 non emergent craniotomies, national readmission database assessing predictors for readmission due to VTE | Advancing age Increasing length of stay Steroid use Transfer to institutional care facility |
| Rinaldo et al, 2020 | 1622 patients, craniotomy for tumour resection, single centre | Advancing age Motor deficit Postoperative intracranial haemorrhage Prolonged intubation or reintubation were independently associated with increased VTE |
| Faraoni et al, 2018 | European guidelines on perioperative venous thromboembolism prophylaxis: Neurosurgery | Malignancy Length of procedure Reduced mobility |
| Heim et al, 2024 | European guidelines on perioperative venous thromboembolism prophylaxis: first update | For cranial surgery: Advancing age Motor deficit Malignant tumour Long duration of surgery Increased length of hospital stay History of VTE Obesity Meningioma Low Karnofsky score of <80 For spinal surgery: Advancing age History of VTE Presence of malignancy Immobility Diabetes Elevated pre-operative D-dimer levels Major intraoperative bleeding Long or extensive interventions involving cervical or thoracic levels Spinal trauma Spinal tumour |
| Anderson et al, 2019 | American Society of Haematology 2019 guidelines for management of VTE | Reduced mobility |
| Rolston et al, 2014 | Retrospective data analysis from American College of Surgeons NSQIP database | Active cancer Advancing age Long duration of surgery Delayed ambulation Increased length of hospital stay Motor deficit, specifically paresis Inherited thrombophilia |
Table 2 -
International Guidelines for VTE Prophylaxis in Neurosurgery
| European (Heim et al, 2024) | European (Faraoni et al, 2018) | American (Anderson et al, 2019) | NICE UK guidelines (2018) | |
|---|---|---|---|---|
| Cranial | IPCDs LMWH from 24 – 72 hours Non-traumatic intracerebral haemorrhage (ICH), 48 – 96 hours once no blood expansion has been es- | IPCDs LMWH after 24 hours Early mobilisation | IPCDs If high VTE risk/reduced mobility, LMWH as soon as risk of bleeding is reduced | IPCDs LMWH from 24 – 48 hours for 7 – 30 days, or until mobilising, or until discharge |
| Spinal | Spinal cord injury, chemoprophylaxis within 48 hours following trauma or surgery 3 to 6 months of chemoprophylaxis after cord injury with neurological deficit, | LMWH after 24 hours If additional VTE risk factors are present, commence as soon as risk of bleed- | LMWH after 24 – 48 hours for elective surgery | |
| TBI (Traumatic brain injury) | LMWH 24 hours post injury if no surgical intervention and no progression of intracranial haemorrhage on CT scan at 24 hours Early LMWH within 48 hours post injury If urgent surgical interventions performed, delay chemoprophylaxis on a case-by-case basis, balancing risks of haemorrhage and VTE Recommend against routine |
Table 3-
Summary of studies
| Study Type/Patients | Timeframe/Condition | Outcome | |
|---|---|---|---|
| Wagar et al, 2024 | Prospective database review 1551 patients | Administered day 1 and 2 Skull base | 18 intracranial haematomas, 0.8%; Chemoprophylaxis did not significantly increase the risk of intracranial haematoma, p >0.99. Initiating day 1 versus day 2 resulted in similar rates of haematoma. |
| Briggs et al, 2022 | Retrospective review 1087 patients | Administered within 72 hours Brain tumours | Initiating chemoprophylaxis with subcutaneous enoxaparin sodium 40mg once daily, within 72 hours of surgery is safe, while reducing the risk of developing lower extremity |
| Spano et al, 2020 | Systematic review of randomised controlled trial (RCT), prospective observational studies, retrospective reviews and systematic reviews | Administered within 24 – 72 hours TBI with ICH | Early initiation of chemoprophylaxis at 24 – 72 hours is associated with reduced VTE incidence and no increase in intracranial haemorrhage, with a stable interval CT prior to initiating, in 14 out of 17 studies. |
| Lu et al, 2020 | Systematic review/meta-analysis 5036 patients, 11 studies | Administered before versus after 72 hours TBI with ICH | Chemoprophylaxis initiated before 72 hours compared with after 72 hours – no statistically significant difference in incidence of haemorrhage progression but VTE incidence significantly less if initiated before 72 |
| Paciaroni et al, 2021 | Systematic review/meta-analysis including RCT 4609 patients | Administered after 72 hours ICH | Reduction in VTE but no increase in rate of haematoma. Chemoprophylaxis is safe in acute ICH. |
| Yepes-Nuñez et al, 2020 | Systematic review of RCTs and non-randomised controlled studies 10 studies | General neurosurgery | No effect of chemoprophylaxis on mortality. No increase in incidence of major bleeding in 7 RCTs, compared with non-pharmacologic VTE prophylaxis (relative risk, 1.57; 95% confidence interval, 0.70 – 3.50) |
| Shani, 2020 | Systematic review of RCTs and observational studies 2811 patients | Administered from 12 hours to day 5–6 General neurosurgery | Incidence of post operative bleeding and haematoma on chemoprophylaxis was 0.4–1.8%, which is within the limits of usual post operative bleeding. |
| Ellenbogen et al, 2021 | Systematic review/meta-analysis of RCTs and retrospective trials | Spinal surgery | Spinal epidural haematomas and significant bleeding are rare, and incidence is similar with or without chemoprophylaxis. Significant decrease in post op DVTs with chemoprophylaxis |
| Rinaldo et al, 2021 | Retrospective study 1622 patients | Mean initiation at 4.6 days, standard deviation 3.8 Brain tumours | 192 patients received LMWH chemoprophylaxis, 11.8%; 30 instances of clinically significant postoperative haemorrhage occurred, 1.9%; Only 1 haemorrhage occurred after initiation of LMWH chemoprophylaxis, 0.1%. |
Table 4-
Questions for Consensus
| Can it be agreed to start IPCDs on admission or day of surgery and removed once mobilising frequently to the toilet independently, with a stick or walking frame? |
| Can it be agreed to consider chemical VTE prophylaxis at 24 – 48 hours post operatively, with satisfactory post-operative imaging? |
| Can it be agreed to consider chemical prophylaxis at 72 hours post moderate to severe traumatic brain injury, with satisfactory interval imaging? |
| Can it be agreed to start prophylactic enoxaparin or unfractionated heparin? |
| Can we agree on when to stop prophylactic enoxaparin or unfractionated heparin? |
| Can we utilise a guideline to manage our approach and guide decision making, by assessing risk factors? |
| Should the consultant decide on commencing prophylactic enoxaparin or can a registrar make the decision? |