Anticoagulation in
Neurosurgical Procedures
Clinical Guidelines, Challenges, and
Landmark Evidence
Laila Baydhi, PGY3
supervisor : Dr Riadh Dr AlRobaie
Overview of Anticoagulation in Neurosurgery:
Anticoagulants are commonly prescribed to prevent thromboembolic complications
(e.g., stroke prevention in atrial fibrillation, prevention of deep vein thrombosis
(DVT), and pulmonary embolism (PE)).
However, neurosurgical procedures involve high risks of bleeding
. Thus, managing anticoagulation during surgery is essential to reduce the risk of
major bleeding while ensuring the prevention of thromboembolic events.
Anticoagulation reversal is a pivotal issue, especially in urgent neurosurgical
interventions (e.g. urgent evacuation of intracranial hemorrhages , decompressive
spinal surgery )
Challenge
s:
• Acute reversal in urgent/emergent neurosurgical cases
• Anticoagulation in elective preop cases
• Anticoagulation in multitrauma patient
• Anticoagulation in cases of CSVT
• Spontaneous ich in coagulation disorders
• VTE and DIC
• Vascular lesions and anticoagulation
Coagulation system
Add title here
The user can demonstrate on a projector or computer or
print the it into a film to be used in a wider field
COMMON INDICATIONS :
Prevention of cardiovascular disease,
prevention of stroke in atrial
fibrillation and prosthetic heart valves,
Treatment of venous
thromboembolism (DVTand PE).
Reversal of anticoagulation:
Elective patients
Antiplatelet therapy and warfarin stopped a few days before
surgery.
Antiplatelets ; stop 5-7 days
stop warfarin at least 3 days prior to procedure.
INR ≈≤1.4
Patients must be advised for risk of possible complications from
the condition for which they are receiving the agents
6
Reversal of anticoagulation:
Elective patients
Warfarin bridging = thromboembolic risk high:
patients are admitted to hospital a few days before surgery
commenced on heparin while warfarin is stopped.
Full anticoagulation until several hours before surgery (typically
6 hours for unfractionated heparin and 12 hours for low
molecular weight heparin).
Elective surgery postponed if the acute event necessitating
anticoagulation is recent.
7
Reversal of anticoagulation:
Elective patients/Cardiac stents
dual antiplatelet therapy (e.g. ASA+ Plavix®)
mandatory : 4 weeks (90 days is preferable)
at least 1 year with drug-eluting stents (DES) (the
risk declines from ≈ 6% to ≈ 3%).
Even short gaps in drug =significant risk of acute
stent occlusion = elective surgery during this time
is discouraged
8
Reversal of anticoagulation:
Elective patients
Herbal products , supplements.
Often affect platelet aggregation and the coagulation
cascade
waiting 7–14 days after cessation of their use is warranted.
Fish Oil (Omega-3 Fatty Acids)
Garlic
Ginkgo (Ginkgo biloba)
Ginseng
ginger and vitamin E9
Reversal of anticoagulation:
Emergency patients
Rapid and complete reversal of
anticoagulation.
Heparin:
waiting 4–6 hours and repeating PTT may be
deleterious
Reverse with protamine
10
Reversal of anticoagulation:
Emergency patients
Warfarin:
Intravenous vitamin K and prothrombin
complex.
Antiplatelets: Aspirin
Aspirin irreversibly blocks platelet function for the
life of the platelet (= 10 days) 02
10 % of platelets are replenished per day;
One pool of platelets will raise the platelet count by
approximately 50 * 109 platelets.
11
Reversal of anticoagulation:
Emergency patients
Reversal of Clopidogrel (Plavix) :
Effect persists for up to a couple of days
platelets inhibited after drug is discontinued
pre-op reversal by:
Platelets: 2 pools of platelets may be given
(Beshay et al. 2010 ).
Desmopressin (DDAVP®)
FFP
Beshay JE , Morgan HM , Madden C , Yu W , Sarode R ( 2010 ). Emergency reversal of
anticoagulation and antiplatelet therapies in neurosurgical
12 patients . J Neurosurg ; 112 : 307 – 18 .
Reversal of anticoagulation:
Emergency patients
Reversal of Clopidogrel (Plavix) :
In cases with continued oozing in the first day or so after
discontinuing Plavix:
Recombinant activated coagulation factor VII (rFVIIa): (≈
$10,000 per dose),
balanced against the cost of repeat craniotomy, increased
ICU stay and additional morbidity
Platelets every 8 hours for 24 hours.
13
Reversal of anticoagulation:
Emergency patients
The role of platelet transfusions in conservatively managed
intracerebral haemorrhage is unclear (Morgenstern et al. 2010 ).
Morgenstern LB , Hemphill C , Anderson C , et al . ( 2010 ). Guidelines for the management of
spontaneous intracerebral hemorrhage. A guideline for healthcare professionals from the American
Heart ssociation/American Stroke Association . Stroke ; 41 : 2108 – 29 .
14
Pantient on Anticoagulation for surgery
Postoperative issues
Venous thromboembolism (VTE)
prophylaxis
Recommencement of anticoagulation
15
Contraindications to heparin
Contraindications to full anticoagulation with heparin
include:
recent severe head injury
recent craniotomy
patients with coagulopathies
hemorrhagic infarction
bleeding ulcer or other inaccessible bleeding site
uncontrollable hypertension
severe hepatic or renal disease
<4–6 hours before an invasive procedure
brain tumor
Massive PE should be treated with anticoagulation in most
cases despite intracranial risks.
16
Venous thromboembolism (VTE) prophylaxis
Incidence of VTE in neurosurgical patients is high
Low-dose heparin reduced the risk of VTE with a slight
increase in hemorrhagic events,
• (9.1 % absolute risk reduction in VTE; 0.7 % absolute risk
increase in ICH) (Hamilton et al. 2011 ).
If risk of major bleeding is low +increased risk of VTE:
mechanical prophylaxis
heparin (usually commenced 12–24 hours postoperatively).
NICE ( 2010 ). Venous thromboembolism — reducing the risk. NICE Guideline CG92 .
17
Venous thromboembolism (VTE) prophylaxis
• If cranial or spinal haemorrhage,
• heparin prophylaxis not recommended
until the lesion is secured or the condition is
stable
Morgenstern LB , Hemphill C , Anderson C , et al . ( 2010 ). Guidelines for
the management of spontaneous intracerebral hemorrhage. A guideline
for healthcare professionals from the American Heart
Association/American Stroke Association . Stroke ; 41 : 2108 – 29 .
Recommencement of anticoagulation
• Anticoagulation should be restarted as soon as
the risk of haemorrhage from a particular
condition has passed.
• Withholding warfarin for up to 2 weeks is safe in
patients with prosthetic heart valves.
Romualdi E , Micieli E , Ageno W , Squizzato A ( 2009 ).
Oral anticoagulant therapy in patients with mechanical heart
valve and intracranial haemorrhage . Thromb Haemost ; 101
: 290 – 7 .
22
• All anticoagulants increase the risk of ICH.
• Anticoagulation increased the risk of
recurrent ICH three-fold (Vermeer et al.
2002 ).
• Individual risk varies :
age,
comorbidities,
intensity of anticoagulation,
lifestyle
23
• When to restart anticoagulation ?
• Decision on:
risk of recurrent ICH,
risk of thromboembolism,
overall neurological status of the
patient.
24
Patients with Chronic Subdural
Hematomas
25
Patients with Chronic Subdural
Hematomas
26
References :
1.Goodman & Gilman’s Manual of Pharmacology and Therapeutics
2. Khaldi et al., Venous Thromboembolism: deep vein thrombosis and pulmonary
Embolism in a neurosurgical population. J Neurosurg 2011;114:40-6.
3. Hacker et ., Subcutaneous heparin doesnot increase post operative complications
In Neurosurgical patients. J Critical Care 2012;27:250-4.
4. MacDoanld RL et al., Safety of peri-operative subcutaenous heaprin for prophylaxis of
Venous thromboembolism in patients undegoing craniotomy. Neurosurgery 1999;45:245-51.
5. Constantini S et al., Safety of perioperative minidose heparin in pateints undergoing brain
Tumor surgery: A prospective randomized double blind study. J Neurosurg 2001;94:918-21
6. DickinsonLD et al., Enoxaparin increases the incidence of post operative intracranial
Hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in
Patients with brain tumors. Neurosurgery 1998;43:1074-81
THANK YOU
QUESTIONS
