Rychen Jonathan, Weiger Valentin F, Halbeisen Florian S, Ebel Florian, Ullmann Muriel, Mariani Luigi, Guzman Raphael, Soleman Jehuda
1Department of Neurosurgery.
2Surgical Outcome Research Center Basel.
Neurosurg Focus. 2023 Oct;55(4):E6. doi: 10.3171/2023.7.FOCUS23357.
Discontinuation of antithrombotics (AT) prior to elective cranial procedures is common practice, despite the higher risk of thromboembolic complications in these patients. The aim of this study was to investigate the risks and benefits of a new perioperative management protocol of continuation or ultra-early AT resumption in elective cranial procedures.
This study was an analysis of a prospectively collected cohort of patients undergoing elective cranial surgery with (AT group) and without (control group) AT. For extraaxial or shunt surgeries, acetylsalicylic acid (ASA) was continued perioperatively. For intraaxial pathologies, ASA was discontinued 2 days before surgery and resumed on postoperative day 3. All other AT were discontinued according to their pharmacokinetics, and resumed on postoperative day 3 after unremarkable postoperative imaging. Additionally, the authors performed a retrospective analysis of patients with AT who underwent surgery before implementation of this new AT management protocol (historical AT group). Primary and secondary outcomes were the incidence of hemorrhagic and thromboembolic complications within 3 months after surgery.
Outcomes of 312 patients were analyzed (83 [27%] in the AT group, 106 [34%] in the control group, and 123 [39%] in the historical AT group). For all 3 patient groups, the most common type of surgery was craniotomy for intraaxial tumors (14 [17%] in the AT group, 28 [26%] in the control group, and 60 [49%] in the historical AT group). The most commonly used AT were ASA (38 [46%] in the AT group and 78 [63%] in the historical AT group), followed by non-vitamin K oral anticoagulants (32 [39%] in the AT group and 18 [15%] in the historical AT group). The total perioperative discontinuation time in the AT group was significantly shorter than in the historical AT group (median of 4 vs 16 days; p < 0.001). The rate of hemorrhagic complications was 4% (95% CI 1-10) (n = 3/83) in the AT group, 6% (95% CI 2-12) (n = 6/106) in the control group, and 7% (95% CI 3-13) (n = 9/123) in the historical AT group (p = 0.5). The rate of thromboembolic complications was 5% (95% CI 1-12) (n = 4/82) in the AT group, 8% (95% CI 3-15) (n = 8/104) in the control group, and 7% (95% CI 3-13) (n = 8/120) in the historical AT group (p = 0.7).
The presented perioperative management protocol of continuation or ultra-early resumption of AT in elective cranial procedures does not seem to increase the hemorrhagic risk. Moreover, it appears to potentially protect patients from thromboembolic complications.
尽管择期颅脑手术患者发生血栓栓塞并发症的风险较高，但在这类手术前停用抗栓药物（AT）仍是常见做法。本研究的目的是调查一种新的围手术期管理方案在择期颅脑手术中持续使用或超早期恢复使用AT的风险和益处。
本研究对前瞻性收集的接受择期颅脑手术的患者队列进行分析，分为使用AT组（AT组）和未使用AT组（对照组）。对于颅外或分流手术，围手术期持续使用阿司匹林（ASA）。对于脑内病变，术前2天停用ASA，术后第3天恢复使用。所有其他AT根据其药代动力学停用，并在术后影像学检查无异常后于术后第3天恢复使用。此外，作者对在实施这种新的AT管理方案之前接受手术的使用AT的患者进行了回顾性分析（历史AT组）。主要和次要结局是术后3个月内出血和血栓栓塞并发症的发生率。
分析了312例患者的结局（AT组83例[27%]，对照组106例[34%]，历史AT组123例[39%]）。对于所有3组患者，最常见的手术类型是脑内肿瘤开颅手术（AT组14例[17%]，对照组28例[26%]，历史AT组60例[49%]）。最常用的AT是ASA（AT组38例[46%]，历史AT组78例[63%]），其次是非维生素K口服抗凝剂（AT组32例[39%]，历史AT组18例[15%]）。AT组围手术期总停用时间明显短于历史AT组（中位数为4天对16天；p<0.001）。AT组出血并发症发生率为4%（95%CI 1-10）（n = 3/83），对照组为6%（95%CI 2-12）（n = 6/106），历史AT组为7%（95%CI 3-13）（n = 9/123）（p = 0.5）。AT组血栓栓塞并发症发生率为5%（95%CI 1-12）（n = 4/82），对照组为8%（95%CI 3-15）（n = 8/104），历史AT组为7%（95%CI 3-13）（n = 8/120）（p = 0.7）。
所提出的在择期颅脑手术中持续使用或超早期恢复使用AT的围手术期管理方案似乎不会增加出血风险。此外，它似乎有可能保护患者免受血栓栓塞并发症的影响。
