Therapeutic anticoagulation after craniotomies: is the risk for secondary hemorrhage overestimated?

Objective: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are major causes of postoperative morbidity and mortality in surgery. However, there is neither a standardized protocol for perioperative prevention of DVT or PE in neurosurgery nor a consensus concerning the management of postoperative DVT or PE after craniotomy in the early postoperative course.

Methods: We retrospectively analyzed management and complications in a group of patients with postoperative DVT or PE after craniotomy between 2006 and 2011 to estimate the risk of secondary hemorrhage under therapeutic anticoagulation. The interval between time of craniotomy and diagnosis of PE or DVT, administered anticoagulation, and the appearance of a clinically relevant secondary hemorrhage were analyzed.

Results: Forty-two patients met the given criteria. Indications for surgery were intracranial tumors (n = 33), aneurysms (n = 5), and hematomas (n = 4). PE or DVT was observed between the first and the 28th postoperative day (median, fifth postoperative day). Therapeutic anticoagulation was performed with enoxaparin or heparin (according to partial thromboplastin time levels). Full heparinization was applied in 30 patients between the second and the 30th postoperative day (median, 12th postoperative day). None of these patients developed a secondary hemorrhage.

Conclusion: The documented differences in the anticoagulative drug used, the drug's dosage, and the start of medication reflect the lack of a standardized protocol concerning the treatment of postoperative PE or DVT after craniotomy. A more aggressive management regarding the application of anticoagulative drugs after craniotomy may be justified considering the absence of clinically relevant hemorrhages in this study and the life-threatening potential of perioperative DVT or PE.