Discontinuationof antithrombotics (AT) prior to elective neurosurgical cranial procedures is common practice, due to the fear of potential hemorrhagic complications.1–4However, discontinuation of AT bears a higher risk of thromboembolic complications in patients with cardio- or cerebrovascular diseases.5–10Perioperative myocardial injury (PMI), for instance, is an often underestimated common complication after noncardiac surgery, and is associated with substantial morbidity and mortality.11,12Perioperative management of AT in elective cranial procedures, particularly discontinuation times, is very heterogeneous among neurosurgeons due to the paucity of good evidence in the current literature.13There is some evidence that shorter preoperative (≤ 5 days) and postoperative (≤ 5 days) discontinuation times are not associated with an increased hemorrhagic risk in comparison to longer discontinuation times.14,15Concerning acetylsalicylic acid (ASA), hematological studies have shown that 10% of platelet function is recovered per day after its cessation.16Further studies have demonstrated that sufficient hemostasis is possible with only 20% of platelets being functional.17,18This implies that 2 days of ASA cessation would be adequate for surgical hemostasis. Recent neurosurgical publications even suggest that perioperative continuation of ASA might not increase the hemorrhagic risk.19–23
In order to optimize the risk-benefit balance between hemorrhagic and thromboembolic complications in patients taking AT for secondary prevention, we developed a new perioperative AT management protocol for elective cranial procedures. For extraaxial or shunt surgeries, ASA is continued during the perioperative period. For intraaxial pathologies, ASA is discontinued 2 days before surgery and resumed on postoperative day (POD) 3. All other AT are discontinued preoperatively according to their own pharmacokinetics, and resumed on POD 3. The aim of this study was to analyze the risks and benefits of the abovementioned perioperative AT management protocol in elective cranial procedures.
开云体育世界杯赔率
Informed Consent Statement
This study was approved by the local ethics board. Patient informed consent was obtained for all surgeries.
Study Design and Inclusion/Exclusion Criteria
This study was an analysis of a prospectively collected database of a single-center cohort. All consecutive patients with or without AT (AT group vs control group) undergoing an elective cranial procedure at the University Hospital of Basel, Switzerland, between January 2021 and March 2023 were included. Patients in the AT group were treated according to our new perioperative AT management protocol, which was implemented in January 2021. Patients managed with different perioperative AT protocols were excluded (n = 33). Patients receiving ASA for primary prevention were also excluded, because recent studies have shown that ASA should no longer be recommended for primary prevention.24–26Additionally, we performed a retrospective analysis of patients with AT who underwent elective cranial surgery before implementation of the new perioperative AT management protocol (historical AT group). These patients underwent surgery between 2015 and 2017 and had typically longer perioperative AT discontinuation times.
Perioperative AT Management Protocol
The detailed perioperative management protocol for the most commonly used AT is presented inTable 1. For extraaxial or shunt surgeries, ASA was continued during the perioperative period. For intraaxial pathologies, ASA was discontinued 2 days before surgery and resumed on POD 3. POD 1 was defined as the first day after surgery. All other AT were discontinued preoperatively according to their own pharmacokinetics, and were resumed on POD 3. AT were resumed after unremarkable postoperative imaging, consisting of a CT or MR image, according to the surgeon’s preference. In cases involving a hemorrhagic complication, further management of the AT medication was individualized to the patient’s situation and cardiovascular risk profile. All patients wore surgical stockings, were mobilized on POD 1, and received low-molecular-weight heparin as thrombosis prophylaxis during the hospitalization (pre- and postoperatively without interruption). In cases involving high-risk patients in need of a bridging therapy, unfractionated heparin was stopped 4 hours before surgery and resumed 6 hours postoperatively in a prophylactic dose. After unremarkable postoperative imaging at POD 1, the dose of heparin was progressively increased in order to reach the therapeutic dose at POD 3.
Perioperative management protocol for the most commonly used AT
| AT | Preop Discontinuation Time (day) | Postop Resumption Time (day) |
|---|---|---|
| ASA | ||
| Shunt surgery/craniotomy for extraaxial lesions/TSS | 0 | 0 |
| Craniotomy for intraaxial lesions | 2 | POD 3 |
| Clopidogrel | 7 | POD 3 |
| Prasugrel | 9 | POD 3 |
| Ticagrelor | 5 | POD 3 |
| Warfarin | 7 | POD 3 |
| Apixaban* | ||
| GFR >30 mL/min | 2 | POD 3 |
| GFR ≤30 mL/min | 3 | POD 4 |
| Rivaroxaban* | ||
| GFR >30 mL/min | 2 | POD 3 |
| GFR ≤30 mL/min | 3 | POD 4 |
| Edoxaban* | ||
| GFR >30 mL/min | 2 | POD 3 |
| GFR ≤30 mL/min | 3 | POD 4 |
| Dabigatran* | ||
| GFR >50 mL/min | 3 | POD 3 |
| GFR 30–50 mL/min | 4 | POD 3 |
| GFR <30 mL/min | 5 | POD 4 |
| Heparin* | 4 hrs | POD 3 |
| Dalteparin* | 1 | POD 3 |
| Nadroparin* | 1 | POD 3 |
| Enoxaparin* | 1 | POD 3 |
GFR = glomerular filtration rate.
Information provided for the therapeutic dose of the antithrombotic medication.
Outcome Analysis
The primary outcome was the incidence of postoperative hemorrhagic complications within 3 months. A hemorrhagic complication was defined as a symptomatic bleeding and/or a bleeding requiring surgical revision. The time period of 3 months after surgery was chosen in order to assess late hemorrhagic complications such as a postoperative chronic subdural hematoma. At the 3-month follow-up, a postoperative imaging study was only performed if the surgeon had previously planned a specific radiological follow-up or in cases involving a symptomatic patient.
第二个结果是periope的发病率rative thromboembolic complications occurring from the time of AT discontinuation (or the time of surgery in cases with AT continuation) up to 3 months after surgery. Screening of asymptomatic patients for potential thromboembolisms was not performed. Diagnostic investigations were only undertaken in cases involving symptomatic patients. Iatrogenic cerebral infarctions were not considered to be thromboembolic complications.
Statistical Analysis
Descriptive data analyses were conducted to summarize the characteristics of the data set. For qualitative data, the number of observations and their respective percentages were reported. For quantitative normally distributed data, the mean and standard deviation were used. For nonnormally distributed data, we used the median and range. Univariable logistic regression analyses were performed to assess the association between the type of intervention and each outcome. To investigate differences between the intervention groups, pairwise comparisons using the Tukey method to account for multiple comparisons were conducted.27This method enabled direct comparisons between each pair of intervention groups, while maintaining control over the overall error rate. Additionally, univariable and multivariable logistic regression analyses were performed to evaluate potential risk factors for the occurrence of complications. Furthermore, we performed individual logistic regression models with Firth’s bias correction to explore the differences in postoperative complications among the different types of surgery and AT.28All models have been corrected for the type of intervention. The results were reported as odds ratios with corresponding 95% confidence intervals and p values. The level of significance was set at 0.05. All analyses were performed with R statistical software (R Core Team,http://www.R-project.org/).29
Results
A total of 312 patients were included in the final analysis, consisting of the AT group (n = 83 [26.6%]), the control group (n = 106 [34%]), and the historical AT group (n = 123 [39.4]%). Baseline characteristics are presented inTable 2. The types of surgeries for the different patient groups are presented inFig. 1. 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) (Table 2andFig. 1). The types of AT are depicted inFig. 2. 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 (NOAC, 32 [39%] in the AT group and 18 [15%] in the historical AT group). In the AT group, AT were discontinued according to the perioperative management protocol presented inTable 1. In the historical AT group, the median preoperative discontinuation time was 7 days (range 0–124) for ASA, 7 days (range 5–9) for other antiplatelet drugs, 5 days (range 1–122) for NOAC, and 7 days (range 0–14) for vitamin K antagonists (VKA). The median postoperative discontinuation time was 8 days (range 1–91) for ASA, 7.5 days (range 5–10) for other antiplatelet drugs, 8.5 days (range 1–108) for NOAC, and 12 days (range 1–31) for VKA. 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). In the AT group all patients received postoperative imaging, which was typically performed on POD 1 when the AT medication had to be resumed on POD 3. However, some patients had a postoperative imaging session at a later point in time in cases with perioperative ASA continuation (median POD 1, range POD 0–11).
Summary of the baseline characteristics in 312 patients who underwent elective cranial procedures
| Variables | AT Group | Control Group | Historical AT Group |
|---|---|---|---|
| No. of patients (%) | 83 (26.6) | 106 (34.0) | 23 (39.4) |
| Median age in yrs | 67, range 35–86 | 56, range 16–84 | 70, range 34–88 |
| Female sex | 25 (30.1) | 50 (47.2) | 53 (43.1) |
| Median preop blood test values | |||
| Platelets, g/L | 235, range 121–555 | 252, range 74–468 | 234, range 99–709 |
| Hemoglobin, g/L | 135, range 93–168 | 135年,91 - 170不等 | 130, range 77–181 |
| INR | 1.1, range 0.9–2.3 | 1, range 0.9–1.3 | 1, range 0.9–1.6 |
| AT type | |||
| ASA | 38 (45.8) | 78 (63.4) | |
| Other antiplatelet drugs | 2 (2.4) | 2 (1.6) | |
| NOAC | 32 (38.6) | 18 (14.6) | |
| VKA | 2 (2.4) | 15 (12.2) | |
| Heparin | 5 (6.0) | 0 (0) | |
| Combination | 4 (4.8) | 10 (8.1) | |
| AT indication | |||
| Cardiovascular &/or cerebrovascular disease | 32 (38.6) | 55 (44.7) | |
| 心房fibrillation | 17 (20.5) | 14 (11.4) | |
| DVT &/or PE | 10 (12.0) | 0 (0) | |
| Primary prevention | 0 (0) | 30 (24.4) | |
| Others* | 24 (28.9) | 1 (0.8) | |
| Unknown | 23 (18.7) | ||
| Need for preop correction of coagulation† | 3 (3.6) | 2 (1.9) | 8 (6.5) |
| Type of surgery | |||
| Craniotomy for tumor surgery (intraaxial) | 14 (16.9) | 28 (26.4) | 60 (48.8) |
| Craniotomy for tumor surgery (extraaxial) | 12 (14.5) | 23 (21.7) | 40 (32.5) |
| TSS | 12 (14.5) | 21 (19.8) | 0 (0) |
| Craniotomy for vascular surgery | 9 (10.8) | 6 (5.7) | 23 (18.7) |
| Shunt surgery | 8 (9.6) | 6 (5.7) | 0 (0) |
| 头颅成形术 | 10 (12.0) | 8 (7.5) | 0 (0) |
| Others‡ | 18 (21.7) | 14 (13.2) | 0 (0) |
DVT = deep venous thrombosis; PE = pulmonary embolism.
Unless otherwise indicated, values are expressed as the number of patients (%).
Other AT indications: thromboses of jugular, subclavian, portal, and cerebral veins; hereditary thrombophilia.
Correction of coagulation was performed with vitamin K, tranexamic acid, prothrombin complex concentrate, or thrombocytes.
其他类型的手术:粘液囊肿切除,endoscopic third ventriculostomy, deep brain stimulation, biopsy, burr hole trephination.
Types of surgery.A:AT group.B:Control group.C:Historical AT group.
Types of AT.Left:AT group.Right:Historical AT group.
Primary Outcome: Hemorrhagic Complications
The rate of hemorrhagic complications was 3.6% (95% CI 0.8–10.2) (n = 3/83) in the AT group, 5.7% (95% CI 2.1–12) (n = 6/106) in the control group, and 7.3% (95% CI 3.4–13.4) (n = 9/123) in the historical AT group (p = 0.5) (Fig. 3).
Hemorrhagic complication rates. The table within the figure outlines the pairwise post hoc test results of univariable logistic regression between the 3 groups. No significant differences were found.
Among the 18 patients in the entire cohort with hemorrhagic complications, 6 patients (33.3%) developed a chronic subdural hematoma within 3 months, 4 patients (22.2%) suffered from a postoperative acute subdural hematoma, 4 patients (22.2%) had a postoperative intracerebral hemorrhage, and 4 patients (22.2%) had an epistaxis after transsphenoidal surgery (TSS). All patients with hemorrhagic complications were symptomatic; 8 patients (44.4%) needed surgical revision, 5 patients (27.8%) could be managed conservatively, the 4 patients (22.2%) with epistaxis underwent a bedside intervention (nasal tamponade or silver nitrate application), and 1 patient (5.6%) (85-year-old patient in the control group) died of the hemorrhagic complication.
Secondary Outcome: Thromboembolic Complications
The rate of thromboembolic complications was 4.9% (95% CI 1.3–12) (n = 4/82) in the AT group, 7.7% (95% CI 3.4–14.6) (n = 8/104) in the control group, and 6.7% (95% CI 2.9–12.7) (n = 8/120) in the historical AT group (p = 0.7) (Fig. 4).
Thromboembolic complication rates. The table within the figure outlines the pairwise post hoc test results of univariable logistic regression between the 3 groups. No significant differences were found. Although there may be differences between the groups, the current analysis does not provide enough statistical power to detect them.
Among the 20 patients in the entire cohort with thromboembolic complications, 13 patients (65%) suffered from an ischemic stroke, 3 patients (15%) developed a pulmonary embolism, 2 patients (10%) had a deep venous thrombosis, 1 patient (5%) a sinus venous thrombosis, and 1 patient (5%) had an NSTEMI (non–ST-elevation myocardial infarction).
Potential Predictors of Hemorrhagic and Thromboembolic Complications
We studied potential predictors of hemorrhagic and thromboembolic complications. In the uni- and multivariable logistic regression analysis, a higher international normalized ratio (INR) and higher intraoperative blood loss were significantly predictive for hemorrhagic complications (Table 3). In the univariable logistic regression analysis, lower postoperative hemoglobin levels and vascular surgery were found to be predictive for hemorrhagic complications (Table 4). The use of heparin was shown to be a significant predictor for thromboembolic complications (Table 4).
Univariable and multivariable logistic regression results for hemorrhagic and thromboembolic complications
| Variables | Hemorrhagic Complications | Thromboembolic Complications | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Univariable* | Multivariable* | Univariable* | Multivariable* | |||||||||
| OR | 95% CI | p Value | OR | 95% CI | p Value | OR | 95% CI | p Value | OR | 95% CI | p Value | |
| Age (yrs) | 1.032 | 0.99–1.08 | 0.132 | 1.03 | 0.983–1.085 | 0.223 | 1.023 | 0.986–1.065 | 0.237 | 1.024 | 0.985–1.067 | 0.237 |
| Sex (male) | 2.013 | 0.732–6.453 | 0.181 | 3.035 | 0.897–13.24 | 0.076 | 1.376 | 0.542–3.786 | 0.508 | 1.155 | 0.426–3.34 | 0.78 |
| Platelets preop, g/L | 0.999 | 0.993–1.005 | 0.826 | 0.999 | 0.992–1.005 | 0.756 | 0.999 | 0.993–1.004 | 0.746 | 1 | 0.994–1.006 | 0.97 |
| INR preop | 23.11 | 1.712–305.8 | 0.021 | 46.2 | 1.377–1880 | 0.034 | 0.878 | 0.007–18.12 | 0.947 | 0.826 | 0.007–28.27 | 0.925 |
| Need for preop correction of coagulation | 1.157 | 0.062–6.474 | 0.894 | 0.14 | 0.002–1.769 | 0.147 | 1.085 | 0.058–5.999 | 0.94 | 0.849 | 0.04–5.828 | 0.886 |
| Hemoglobin preop, g/L | 0.994 | 0.967–1.023 | 0.687 | 1.023 | 0.974–1.073 | 0.363 | 1.002 | 0.976–1.03 | 0.889 | 0.988 | 0.942–1.033 | 0.594 |
| Hemoglobin postop, g/L | 0.97 | 0.946–0.996 | 0.023 | 0.969 | 0.924–1.019 | 0.215 | 1.002 | 0.978–1.028 | 0.876 | 1.014 | 0.97–1.065 | 0.551 |
| Blood loss intraop, mL | 1.002 | 1.001–1.003 | <0.001 | 1.001 | 1–1.003 | 0.037 | 1 | 0.999–1.001 | 0.358 | 1.001 | 0.999–1.002 | 0.367 |
Boldface type indicates statistical significance (p < 0.05).
All results have been adjusted for the different intervention groups (not shown). The univariable model assesses the association between a single predictor variable and the outcome, without considering the effects of any other variables (except intervention group). The multivariable model takes all predictor variables simultaneously into account.
Univariable logistic regression results for hemorrhagic and thromboembolic complications by AT types, AT discontinuation times, and types of surgery
| Variables | Hemorrhagic Complications | Thromboembolic Complications | ||||
|---|---|---|---|---|---|---|
| OR | 95% CI | p Value | OR | 95% CI | p Value | |
| AT types | ||||||
| ASA | 0.675 | 0.21–2.16 | 0.5 | 1.03 | 0.328–3.44 | 0.958 |
| Other antiplatelet drugs | 1.77 | 0.013–18.4 | 0.727 | 1.68 | 0.013–17.2 | 0.747 |
| NOAC | 3.31 | 0.931–11.3 | 0.064 | 0.382 | 0.04–1.76 | 0.24 |
| VKA | 1.15 | 0.118–5.5 | 0.882 | 1.23 | 0.126–5.96 | 0.823 |
| Heparin | 1.96 | 0.014–24.6 | 0.691 | 21.6 | 2.65–191 | 0.006 |
| Combinations | 0.453 | 0.004–3.81 | 0.547 | 1.75 | 0.179–8.44 | 0.566 |
| AT discontinuation times (days) | 1.009 | 0.98–1.03 | 0.439 | 0.999 | 0.958–1.024 | 0.992 |
| Types of surgery | ||||||
| Craniotomy for tumor surgery (extraaxial) | 0.879 | 0.258–2.48 | 0.818 | 1.42 | 0.501–3.65 | 0.49 |
| Craniotomy for tumor surgery (intraaxial) | 0.35 | 0.087–1.08 | 0.068 | 1.13 | 0.408–2.91 | 0.812 |
| Craniotomy for vascular surgery | 5.37 | 1.86–14.9 | 0.003 | 1.5 | 0.374–4.64 | 0.528 |
| TSS | 4 | 1.02–14.9 | 0.047 | 1.67 | 0.398–5.65 | 0.45 |
| Shunt surgery | 0.632 | 0.005–5.49 | 0.741 | 0.468 | 0.004–3.92 | 0.563 |
| 头颅成形术 | 0.482 | 0.004–4.1 | 0.582 | 0.356 | 0.003–2.92 | 0.41 |
| Others* | 0.251 | 0.002–2.09 | 0.248 | 0.63 | 0.066–2.82 | 0.586 |
Boldface type indicates statistical significance (p < 0.05).
其他类型的手术:粘液囊肿切除,endoscopic third ventriculostomy, deep brain stimulation, biopsy, burr hole trephination.
Discussion
This study suggests that the presented perioperative management protocol of continuation or ultra-early resumption of AT in elective craniotomies does not seem to increase the risk for hemorrhagic complications. The fact that the AT group had the lowest hemorrhagic complication rate (although without significant difference) might be random due to the small sample size or potentially because the surgeons performed extra-meticulous hemostasis knowing that the patients were receiving continuous AT or would receive AT already on POD 3.
The presented perioperative AT management protocol appears to potentially protect patients from thromboembolic complications. Indeed, the rate of thromboembolic complications was the lowest in the AT group. Although there may be differences between the groups, the current analysis did not provide enough statistical power to detect them. This potential benefit needs to be further investigated in a larger patient cohort. In our study, the rate of thromboembolic complications is probably underestimated because patients were not screened perioperatively with electrocardiography, cardiac troponin measurements, or ultrasound examinations of the legs. For instance, perioperative troponin screening in the setting of noncardiac surgery leads to a PMI incidence ranging from 13% to 16%. PMI is known to be associated with substantial short- and long-term mortality.11,12We recommend that practitioners consider screening tools for thromboembolic complications and use PMI as an outcome parameter for future studies.
我们继续extraaxial或分流手术,亚撒ed during the perioperative period. For intraaxial pathologies we were more cautious and discontinued ASA 2 days before surgery. The rationale for these 2 days of discontinuation comes from hematological studies stating that 2 days are needed to achieve sufficient hemostasis.16–18The study by Hanalioglu et al. suggested the safety of ASA continuation in elective craniotomies for brain tumors.20However, intraaxial tumor location was shown to have a marginal effect (p = 0.087) on hemorrhagic complications in this study, warranting some caution for intraaxial lesions.20A meta-analysis by our own research group reinforced the evidence in favor of ASA continuation in elective craniotomies, with a similar hemorrhagic complication rate in the ASA continuation and discontinuation group (3% [95% CI 0.01–0.05] vs 3% [95% CI 0.01–0.09]; p = 0.9).19Taken together, it seems that more and more evidence exists for the safety of continuing ASA treatment during elective cranial surgery. In the presented perioperative management protocol, AT other than ASA were discontinued preoperatively according to their own pharmacokinetics, and resumed on POD 3. Because most hemorrhagic complications occur in the first postoperative hours,30we believed that the resumption of AT on POD 3 is reasonable. Indeed, the study by Ullmann et al. for tumor and the one by Ebel et al. for vascular surgery showed that shorter preoperative (≤ 5 days) and postoperative (≤ 5 days) discontinuation times are not associated with an increased hemorrhagic risk in comparison to longer discontinuation times.14,15
To the best of our knowledge, the presented study protocol has the shortest AT postoperative resumption times found in the literature, legitimizing the term ultra-early resumption. Mehta et al. recently conducted a literature review regarding the resumption of therapeutic anticoagulation after elective craniotomy for patients with atrial fibrillation.9The authors stratify the patients in three different groups: confident intraoperative hemostasis, tenuous hemostasis and a congestive heart failure, hypertension, age 75 years or older, diabetes, prior stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category (CHA2DS2-VASc) score ≥ 4, and tenuous hemostasis and a CHA2DS2-VASc score < 4.31According to the stratification group, the authors recommend resumption of anticoagulation on POD 7, POD 7–10, and POD 10–12, respectively.9According to the results of our own study, we believe that a more aggressive protocol with earlier postoperative resumption of AT is warranted.
In the uni- and multivariable logistic regression analysis, a higher INR was predictive for hemorrhagic complications, which is somewhat intuitive and expected (Table 3). A higher intraoperative blood loss was also predictive for hemorrhagic complications in the uni- and multivariable analysis (Table 3). In fact, strongly vascularized lesions cause higher intraoperative blood losses and may lead to a higher postoperative hemorrhagic risk, particularly when the lesion cannot be resected completely. Similarly, lower postoperative hemoglobin levels were found to be predictive for hemorrhagic complications in the univariable analysis (Table 3). In our univariable analysis, vascular surgery was found to be predictive for hemorrhagic complications (Table 4). No clear explanation for this finding could be found—hence caution should be used when interpreting these results, due to the low event rate in our cohort. Hanalioglu et al. did not find any significant predictive factors for hemorrhagic complications in a patient cohort with and without ASA.20
Concerning thromboembolic complications, the only predictive factor that could be found in the univariable logistic regression analysis was the use of heparin (Table 4). Indeed, a bridging therapy with heparin is only indicated in high-risk patients (e.g., patients with a mechanical heart valve), which explains the higher perioperative thromboembolic risk in those patients. It is well known that patients with meningioma have a higher risk of developing postoperative venous thromboembolisms.32–34Our cohort was presumably too small to confirm these results. Others, however, were able to show that male sex, and skull base meningiomas in particular, were independent predictors for thromboembolic complications.20
Strengths
Our study addresses a very relevant topic of daily neurosurgical practice, for which the paucity of evidence leads to heterogeneous and somewhat arbitrary management strategies. We have elaborated a clear and easily applicable perioperative AT management protocol for elective craniotomies and have demonstrated its feasibility in the context of this prospective study. To the best of our knowledge, there are no similar studies defining and analyzing standardized postoperative ultra-early resumption times for various AT. Clearly, further prospective studies from other centers are needed to underline our results.
Limitations
本研究的主要局限是小山姆ple size of the different patient cohorts (AT, control, and historical AT groups), which precludes us from drawing strong conclusions from the analyzed data. In addition, the compared patient cohorts were relatively heterogeneous. In fact, the historical AT group included only craniotomies for tumor and vascular surgery, whereas the AT and control groups also comprised TSS, shunt, and cranioplasty surgeries. The inclusion of patients with various AT slightly limits the interpretation and generalizability of the study’s results because of the different pharmacological mechanisms of action and risk profiles. The heterogeneity in surgery and AT types potentially resulted in design biases. The lack of blinding of the surgeons to the patient groups potentially led to a performance bias if surgeons performed extra-meticulous hemostasis knowing that the patients were in the AT group. Finally, we advise caution in the interpretation of the uni- and multivariable logistic regression analysis due to the relatively small number of event numbers within our cohort.
Conclusions
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. These findings need to be further investigated in larger patient cohorts.
Disclosures
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Author Contributions
Conception and design: Rychen, Soleman. Acquisition of data: Weiger, Ebel, Ullmann. Analysis and interpretation of data: Rychen, Weiger, Halbeisen, Soleman. Drafting the article: Rychen, Weiger. Critically revising the article: Weiger, Ebel, Mariani, Guzman, Soleman. Reviewed submitted version of manuscript: Rychen, Weiger, Guzman, Soleman. Approved the final version of the manuscript on behalf of all authors: Rychen. Statistical analysis: Weiger, Halbeisen. Administrative/technical/material support: Mariani, Guzman. Study supervision: Mariani, Soleman.
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