Swann K W, Black P M, Baker M F
J Neurosurg. 1986 Apr;64(4):563-7. doi: 10.3171/jns.1986.64.4.0563.
The authors present a retrospective analysis of the management of deep vein thrombosis (DVT) and pulmonary embolism (PE) in neurosurgical patients at the Massachusetts General Hospital from January, 1978, through June, 1982. There were 44 cases of DVT and 13 cases of PE. Management modalities included observation only, femoral vein ligation, inferior vena cava clipping, transvenous placement of an inferior vena cava filter or umbrella, and anticoagulation therapy. Six (75%) of eight patients with symptomatic DVT who were managed by observation alone had subsequent pulmonary emboli, and three (38%) died. Femoral vein ligation was followed by PE in one of four cases and led to significant leg swelling in two others. Neither observation alone nor femoral vein ligation can be recommended as routine management options. Partial inferior vena cava interruption with a De Weese clip, Kim-Ray Greenfield filter, or Mobin-Uddin umbrella all successfully prevented pulmonary emboli. The major problem associated with these methods was leg edema, which occurred in 47% of patients with clip placement, 25% with filter placement, and 21% with a Mobin-Uddin umbrella. Anticoagulation therapy was associated with a complication rate of 29% and a mortality rate of 15%. Fatal PE and paradoxical hypercoagulability with gangrene of a lower extremity were the causes of death. In one patient, hemorrhage into a glioblastoma occurred following discontinuation of anticoagulation therapy when the coagulation parameters were normal. The authors conclude that: 1) management with observation alone of patients with symptomatic DVT places the patient at risk for the development of life-threatening pulmonary emboli; 2) the safety and timing of therapeutic anticoagulation in postoperative neurosurgical patients or patients with tumors is unclear; and 3) partial interruption of the inferior vena cava with a transvenous filter successfully prevents PE and may represent a safer alternative to anticoagulation therapy.
作者对1978年1月至1982年6月期间在马萨诸塞州总医院神经外科患者中深静脉血栓形成（DVT）和肺栓塞（PE）的管理进行了回顾性分析。有44例DVT和13例PE。管理方式包括仅观察、股静脉结扎、下腔静脉夹闭、经静脉放置下腔静脉滤器或伞以及抗凝治疗。仅通过观察进行管理的8例有症状DVT患者中，有6例（75%）随后发生了肺栓塞，3例（38%）死亡。4例股静脉结扎患者中有1例随后发生了PE，另外2例出现了明显的腿部肿胀。单独观察和股静脉结扎均不能作为常规管理选择推荐。用De Weese夹、Kim-Ray Greenfield滤器或Mobin-Uddin伞进行部分下腔静脉阻断均成功预防了肺栓塞。与这些方法相关的主要问题是腿部水肿，夹闭放置患者中47%出现，滤器放置患者中25%出现，Mobin-Uddin伞放置患者中21%出现。抗凝治疗的并发症发生率为29%，死亡率为15%。致命性PE和下肢坏疽伴反常高凝是死亡原因。1例患者在凝血参数正常时停用抗凝治疗后，胶质母细胞瘤内发生了出血。作者得出结论：1）对有症状DVT患者仅进行观察管理会使患者面临发生危及生命肺栓塞的风险；2）术后神经外科患者或肿瘤患者进行治疗性抗凝的安全性和时机尚不清楚；3）经静脉滤器部分阻断下腔静脉成功预防了PE，可能是抗凝治疗更安全的替代方法。
