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 |
| Buchanan et al, 2019 | 89,450 non emergent craniotomies, national readmission database assessing predictors for readmission due to VTE | Advancing age |
| Rinaldo et al, 2020 | 1622 patients, craniotomy for tumour resection, single centre | Advancing age |
| Faraoni et al, 2018 | European guidelines on perioperative venous thromboembolism prophylaxis: Neurosurgery | Malignancy |
| Heim et al, 2024 | European guidelines on perioperative venous thromboembolism prophylaxis: first update | For cranial surgery: |
| 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 |
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? |
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 | IPCDs | IPCDs | IPCDs |
| Spinal | Spinal cord injury, chemoprophylaxis within 48 hours following trauma or surgery | LMWH after 24 hours | 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 |
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. |
| 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%. |