Sjåvik Kristin, Bartek Jiri, Solheim Ole, Ingebrigtsen Tor, Gulati Sasha, Sagberg Lisa Millgård, Förander Petter, Jakola Asgeir Store
Department of Neurosurgery, University Hospital of North Norway, Tromsø, Norway.
Department of Neurosurgery, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
World Neurosurg. 2016 Apr;88:320-326. doi: 10.1016/j.wneu.2015.12.077. Epub 2015 Dec 31.
Venous thromboembolism (VTE) is a serious complication after intracranial meningioma surgery. To what extent systemic prophylaxis with pharmacotherapy is beneficial with respect to VTE risk, or associated with increased risk of bleeding and postoperative hemorrhage, remains debated. The current study aimed to clarify the risk/benefit ratio of prophylactic pharmacotherapy initiated the evening before craniotomy for meningioma.
In a Scandinavian population-based cohort, we conducted a retrospective review of 979 operations for intracranial meningioma between 2007 and 2013 at 3 neurosurgical centers with population-based referral. We compared 2 different treatment strategies analyzing frequencies of VTE and proportions of postoperative intracranial hematomas requiring surgery or intensified subsequent observation or care (intensive care unit or other intensified observation or treatment). One neurosurgical center favored preoperative prophylaxis with low-molecular-weight heparin (LMWH) (LMWH routine group) in addition to mechanical prophylaxis, and 2 centers favored mechanical prophylaxis with LMWH only given as needed in cases of delayed mobilization (LMWH as needed group).
In the LMWH routine group, VTE was diagnosed after 24/626 operations (3.9%), and VTE was diagnosed after 11/353 (3.1%) operations in the LMWH as needed group (P = 0.56). Clinically relevant postoperative hematomas occurred after 57/626 operations (9.1%) in the LMWH routine group compared with 23/353 (6.5%) in the LMWH as needed group (P = 0.16). Surgically evacuated postoperative hematomas occurred after 19/626 operations (3.0%) in the LMWH routine group compared with 8/353 operations (2.3%) in the LMWH as needed group (P = 0.26).
There is no benefit of routine preoperative LMWH starting before intracranial meningioma surgery. Neither could we for primary outcomes detect a significant increase in clinically relevant postoperative hematomas secondary to this regimen. We suggest that as needed perioperative administration of LMWH, reserved for patients with excess risk because of delayed mobilization, is effective and also appears to be the safest strategy.
静脉血栓栓塞症（VTE）是颅内脑膜瘤手术后的一种严重并发症。药物进行全身预防在降低VTE风险方面的获益程度，或与出血及术后出血风险增加的相关性，仍存在争议。本研究旨在阐明在脑膜瘤开颅手术前一晚开始预防性药物治疗的风险/获益比。
在一个基于斯堪的纳维亚人群的队列中，我们对2007年至2013年间在3个基于人群转诊的神经外科中心进行的979例颅内脑膜瘤手术进行了回顾性分析。我们比较了两种不同的治疗策略，分析VTE的发生频率以及需要手术或加强后续观察或护理（重症监护病房或其他加强观察或治疗）的术后颅内血肿的比例。一个神经外科中心除了机械预防外，倾向于术前用低分子肝素（LMWH）进行预防（LMWH常规组），另外两个中心倾向于仅在延迟活动的情况下根据需要给予LMWH进行机械预防（LMWH按需组）。
在LMWH常规组中，626例手术中有24例（3.9%）诊断为VTE，在LMWH按需组中，353例手术中有11例（3.1%）诊断为VTE（P = 0.56）。LMWH常规组626例手术中有57例（9.1%）发生了具有临床意义的术后血肿，而LMWH按需组353例手术中有23例（6.5%）发生了此类情况（P = 0.16）。LMWH常规组626例手术中有19例（3.0%）发生了需手术清除的术后血肿，而LMWH按需组353例手术中有8例（2.3%）发生了此类情况（P = 0.26）。
颅内脑膜瘤手术前常规使用LMWH并无益处。对于主要结局，我们也未发现该方案导致具有临床意义的术后血肿显著增加。我们建议，围手术期按需给予LMWH，仅用于因延迟活动而存在额外风险的患者，是有效的，而且似乎也是最安全的策略。
