Perioperative antithrombotic management in elective neurosurgery: a survey from the Lombardia Neurocritical Care Network, Italy

BACKGROUND: Perioperative antithrombotic management in neurosurgery carries significant bleeding and thrombosis risks. This survey aimed to provide the first structured analysis of current practices, resource availability, and decision-making heterogeneity across the coordinated neurocritical care network in Lombardia (Lombardy) an administrative region in Northern Italy. METHODS: This cross-sectional, region-wide survey involved all 19 hospitals performing neurosurgery in Lombardy. It analyzed multiple domains of perioperative anticoagulant management, including preoperative risk assessment, laboratory monitoring, use of bridging therapy, reversal strategies, and timing of pharmacologic thromboprophylaxis. The head of service collected responses from two to four experienced colleagues at each center. Participation was voluntary and anonymous, and no patient-level data were collected. Data were analyzed descriptively using R software; categorical variables are expressed as number (percentage) and continuous variables as mean± (SD)median (IQR). RESULTS: The survey revealed marked variability across all domains, with clinical approaches remaining fragmented and largely driven by institutional culture rather than standardized protocols. A systemic lack of data collection on institutional postoperative hemorrhage and deep vein thrombosis epidemiology was found, with available data often based on subjective estimates. There is underutilization of formal thrombotic risk scores (e.g., Padua, IMPROVE) and predominantly reactive use of viscoelastic testing (ROTEM/TEG). Only 20.7% of respondents routinely involve both a Cardiologist and a Hematologist for multidisciplinary assessment. Furthermore, the timing of low-molecular-weight heparin administration varies widely: most responders delay initiation until postoperative day two to four after intracranial procedures, often deviating from guidelines recommending initiation within 24 hours when safe. CONCLUSIONS: The findings highlight the urgent need for structured, consensus-based perioperative anticoagulation pathways tailored to neurosurgical populations. Priority areas include standardizing venous thromboembolism prophylaxis timing and modality, promoting the systematic use of viscoelastic testing, and creating regional registries to track hemorrhagic and thrombotic events and improve evidence-based decision-making.