Joeky Senders

61 Venous thromboembolism en intracranial hemorrhage that patients who develop symptomatic DVTs are unaware of the signs and symptoms until they progress to PE, implicating a possible role for improved patient education in preventing morbidity caused by DVT and PE. In prospective randomized control trials investigating different VTE prophylaxis modalities, Goldhaber et al. screened all craniotomy patients prior to discharge and found 9.3% of patients to have VTE, most of which were asymptomatic in both studies. 46 Most guidelines recommend that prophylactic use of low-molecular weight heparin or unfractionated heparin should be considered in all cancer patients undergoing major surgery. 16-19 In patients undergoing operations for brain tumors, however, the benefits of anticoagulation should be carefully balanced against the risk of ICH. 54,55 Although most guidelines support the use of pharmacological prophylaxis in patients with brain tumors, proper timing of prophylaxis remains controversial and the use of anticoagulation often depends on the surgeon’s preference. 54-56 Recommendations vary between administration throughout hospitalization, 19 up to five to ten days after surgery, 16,17,57 until the patient is mobile, 54 or timing based on the individual risk profile. 58 A lack of scientific evidence is primarily the cause of this variation in recommendations. Recent systematic reviews andmeta-analyses of VTE prophylaxis in patients undergoing craniotomy for a brain tumor have been performed. 59-63 These analyses have compared different VTE prophylaxis modalities, as well as their safety and cost effectiveness, but they do not thoroughly investigate the efficacy over time to determine a recommended time frame for thromboprophylaxis. Only one clinical trial studied the effect of continued prophylaxis up to 12 months after surgery. 15 No significant association was found between prolonged prophylaxis and the rate of both VTE and ICH; however, the trial was stopped early because of expiration of study medication, and the control group received placebo instead of short-term prophylaxis. Many patients may not need or benefit from continuing thromboprophylaxis beyond discharge. Algattas et al. reviewed the safety and effectiveness of several thromboprophylactic strategies and indicated that different regimens may have different efficacies depending on the patient’s VTE risk profile. 59 This highlights the importance of using the appropriate risk profile for optimizing postoperative management. Since the NSQIP data does not contain information on thromboprophylactic strategies, the current study provides limited insight into the efficacy or safety of prophylactic anticoagulation and insufficient evidence to change the current clinical practice with regards to thromboprophylaxis. Therefore, we concur with the current guidelines that recommend pharmaceutic prophylaxis (low-molecular weight heparin or unfractionated heparin) in combination with mechanical prophylaxis (anti-embolism