Joeky Senders

71 Thromboprophylaxis after craniotomy Introduction Cancer patients are at increased risk for venous thromboembolism (VTE). This risk is especially high in brain tumor patients. 1 Among the different brain tumors, high-grade gliomas (HGG) seem particularly at risk for developing a VTE, 2-4 with reported incidences of symptomatic VTE up to 37% throughout the course of the disease, depending on the follow-up time and prophylactic treatment given. 4-18 Although it is controversial whether VTE reduces survival in HGG patients, 2,4,6-8,14,19 VTE certainly reduces their quality of life and remains one of the main reasons for readmission within 30 days after surgery. 20 Besides neurosurgery, many other patient, tumor, and treatment related risk factors for the development of VTE have been identified in HGG patients including old age, 3,5,8,21 male sex, 15 obesity, 15 history of VTE, 6,15 blood group A or AB compared to O, 5 elevated factor VIII, 19 low Karnofsky Performance Scale (KPS) score, 3,15,21 paresis, 2-4,17,18 seizures, 6 glioblastoma histology, 4,8 large tumor size, 5 supra-tentorial location, 2 intra-luminal thrombosis in glioma vessels, 22 craniotomy, 3,7,8,12 initial biopsy before resection, 19 residual tumor tissue after surgery, 7 increased postoperative stay on the ICU 6 or in the hospital, 21 number of hospital admissions, 21 steroid usage, 15 chemotherapy, 18,23 and anti-VEGF therapy. 21 Most guidelines recommend the use of low-molecular weight heparins (LMWHs), often in combination with compression stocking and/or intermittent pneumatic compression, in patients operated for a brain tumor to reduce the risk of VTE; however, proper timing of prophylaxis remains controversial and varies between administration throughout hospitalization, 24 up to 7-10 days after surgery, 25-27 until the patient is mobile, 28 and timing based on the patient’s risk profile or the surgeon’s preference. 29,30 A lack of scientific evidence is primarily the cause of this variation in recommendations, and the risk of intracranial hemorrhage (ICH) make clinicians lean towards a more conservative thromboprophylactic strategy. 31 A recent study demonstrated, however, that the risk of VTE remains considerably high after discharge, especially for pulmonary embolism, whereas ICH occurred predominantly during hospitalization. 32 This suggests a potential role for continuing LMWH administration beyond discharge. In our institution, the duration of postoperative thromboprophylaxis has been prolonged up to 21 days after surgery for an extended period of time. This provides the opportunity to assess the effectiveness of this policy and make a direct comparison with the conventional strategy, prophylactic anticoagulation administered until