Thromboprophylactic management in the neurosurgical patient with high risk for both thrombosis and intracranial bleeding

PURPOSE OF REVIEW: Pharmacologic thromboprophylaxis is indicated in neurosurgery patients having high risk for venous or arterial thrombosis. The pharmacologic thromboprophylaxis, as well as temporary interruption of antithrombotic drugs because of surgery, and possible use of substitutive medication ('bridging therapy') are reviewed. RECENT FINDINGS: Pharmacologic thromboprophylaxis is used for most neurosurgical patients, but clinical practices vary a lot. There are only few reports of the management of neurosurgery patients having mechanical prosthetic heart valves, atrial fibrillation with comorbidities, history of deep venous thrombosis, thrombophilia, or coronary artery stent. These patients present a high risk for both thrombosis and bleeding as temporary interruption of antithrombotic medication as well as a substitutive medication would be indicated. Generally, the bridging therapy with low-molecular-weight heparin (LMWH) is a feasible approach in patients needing interruption of vitamin K antagonists. Experiences in neurosurgery patients emphasize carefully secured hemostasis and tailored dose as well as timing of LMWH. In patients with a recent coronary artery stent scheduled for neurosurgery, an individualized plan is needed. Bridging therapy for antiplatelet agents or novel oral anticoagulants is not yet settled. SUMMARY: Pharmacologic thromboprophylaxis, or bridging therapy, should be tailored according to the individual risks and the type of neurosurgery. The bleeding risk is likely minimized by allowing coagulation capacity to normalize preoperatively and by using reduced doses of LMWH starting relatively late after neurosurgery.