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This Article Full Text (PDF) All Versions of this Article: chest.08-0023v1 134/2/237    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Google Scholar Articles by Collen, J. F. Articles by Moores, L. K. PubMed PubMed Citation Articles by Collen, J. F. Articles by Moores, L. K.

Prevention of venous thromboembolism in neurosurgery: a meta-analysis

From the Department of Medicine (JFC), Walter Reed Army Medical Center, Washington, D.C., Department of Pulmonary Medicine (AFS), Washington Hospital Center, Washington DC, and the Uniformed Services University of the Health Sciences, Bethesda, MD (LKM, JLJ)

Jcollen2002{at}hotmail.com

Abstract

BackgroundVenous thromboembolism (VTE) is an important complication of neurosurgery. Current guidelines recommend pharmacologic prophylaxis in this setting with either unfractionated heparin (UFH) or low-molecular weight heparin (LMWH). We conducted a systematic review asking, "Among patients undergoing neurosurgical procedures, how safe and effective is the prophylactic use of heparin and mechanical devices?"

MethodsWe searched the medical literature to identify prospective trials reporting on VTE prevention (either mechanical or pharmacologic). Rates of VTE and bleeding were our primary endpoints and were pooled using a random effects model.

ResultsWe identified 30 studies reporting on 7779 patients. There were 18 randomized controlled trials and 12 cohort studies. Results of pooled relative risks showed LMWH and intermittent compression devices (ICDs) to be effective in reducing the rate of deep vein thrombosis (LMWH RR:0.60, 95% CI 0.44-0.81, ICD RR:0.41, 95% CI 0.21-0.78). Similar results were seen when pooled rates from all 30 trials were analyzed. In head-head trials there was no statistical difference in the rate of intracranial hemorrhage (ICH) between LMWH and non-pharmacologic methods (RR 1.97, 95% CI 0.64-6.09). Pooled rates of Intracranial hemorrhage and minor bleeding were generally higher with heparin than nonheparin based prophylactic modalities.

ConclusionsIn a mixed neurosurgical population, LMWH and ICDs are both effective in the prevention of VTE. Sensitivity analyses suggest that isolated high risk groups, such as those undergoing craniotomy for neoplasm, may benefit from a combination of methods, suggesting a more individualized approach to these patients.

Key Words: neurosurgery • thromboembolism • thrombosis • intracranial hemorrhages • hemorrhage