Joeky Senders

49 Venous thromboembolism en intracranial hemorrhage Introduction Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), constitutes a major cause of morbidity and mortality in patients undergoing craniotomy for a primary malignant brain tumor. 1-6 Cancer is a recognized risk factor for VTE development in addition to known surgical risk factors, such as venous stasis from perioperative immobility, endothelial injury, and inflammation from the operation itself. 7 Among all cancer types, high-grade gliomas have been shown to result in the second highest lifetime risk for cancer-related VTE and one of the highest risks of perioperative VTE. Rates of postoperative VTE have been reported to be twice as high when comparing craniotomy for any brain tumor versus non-neoplastic diseases. 8-11 VTE has been reported as one of the most frequent major complications after craniotomy for brain tumors with incidences up to 21% in the first three months after surgery. 1-6 Previous studies have identified older age, male sex, Hispanic ethnicity, history of craniotomy, history of VTE, congestive heart failure, coagulopathy, seizures, increased stay on the intensive care unit, prolonged hospital stay, residual tumor tissue, and absence of thromboprophylactic therapy as predictors of VTE after craniotomy for a primary malignant brain tumor. 3,4,6,12-15 Most of these studies have been small, single- center studies, and none of these studies have identified predictors or performed time-to-event analyses stratified for VTE type (DVT versus PE) or clinical setting (during hospitalization versus after discharge). Most patients undergoing surgery for a brain tumor receive pharmaceutic prophylaxis in combination with mechanical prophylaxis in the perioperative setting. 16-19 However, anticoagulation increases the risk of intracranial hemorrhage (ICH), which is one of the most frequent and feared complications in patients undergoing brain tumor surgery. 20 The increased risk of ICH makes the use of prophylactic anticoagulation an issue of great debate and careful balance in this patient population. Although the incidence of ICH is lower compared to VTE events, their outcomes can be at least as detrimental. Only few predictors associated with ICH have been identified including history of craniotomy, use of bevacizumab, and therapeutic anticoagulation for a VTE. 13,21-25 Adequate assessment of the perioperative risk of both VTE and ICH within this patient population, as well as accurately characterizing the timing of thrombotic and hemorrhagic events, is meaningful for tailoring postoperative management to the risk profile of the individual patient.