The Janus face of thromboprophylaxis in patients with high risk for both thrombosis and bleeding during intracranial surgery: report of five exemplary cases

The antithrombotic agents are usually interrupted in fear of bleeding complications before neurosurgery. However, the optimal schematic regimen of substitutive medication to prevent thromboembolic events after surgery is unsettled.

We report five complex neurosurgical cases with high risk for thromboembolism requiring thromboprophylaxis during craniotomy.

In one patient with coronary bare metal stent and antiplatelet therapy, acetylsalicylic acid and clopidogrel was discontinued 5 and 11 days prior to surgery, respectively. Four other patients were on regular warfarin therapy due to previous deep venous thrombosis, pulmonary embolism, or mechanical aortic valve. Adjusted bridging therapy with low-molecular-weight heparin was applied in all cases. The patient with the coronary stent who was managed with reduced-dose dalteparin developed postoperative intracranial hemorrhage despite having platelet and fresh-frozen plasma transfusions, and the patient did not survive. Another patient with a history of lower-extremity deep venous thrombosis developed a postoperative intracranial hematoma but also a recurrence of left lower extremity deep venous thrombosis and had a delayed recovery. The other two patients with history of pulmonary embolism, and one patient having mechanical aortic valve and atrial fibrillation, recovered uneventfully when reduced doses of low molecular weight heparin bridging therapy were administered.

Our observations confirm the complexity of balancing the risks of bleeding and thrombosis in neurosurgical patients on antithrombotic medication. In these patients, the individual bleeding risk is likely minimized by the administration of reduced doses of LMWH relatively late after craniotomy and by delaying the start of warfarin after surgery.