Anticoagulation in neurosurgical patients

OBJECTIVE: Few recommendations have been outlined in the neurosurgical literature regarding when if is safe to initiate postoperative or posthemorrhage anticoagulation (AC), or for what duration it is safe to discontinue AC therapy in patients with clear indications for AC therapy. Our objective was to formulate guidelines for managing AC in neurosurgical patients, based on patients' needs for AC and the risk of complications. METHODS: We conducted a systematic review of the neurosurgical and general surgical literature pertaining directly to postoperative or posthemorrhage management of AC. In addition, we surveyed the general medical, cardiology, cardiothoracic surgery, general surgery, vascular surgery, and neurology literature to determine the risk of thromboembolic complications when AC is stopped in specific patient groups. RESULTS: Postoperative bleeding complications occurred more frequently when correction of coagulation abnormalities was inadequate in the preoperative period, when AC was reinstituted in the early (24-48 h) postoperative period, and when AC was supratherapeutic in the postoperative period. Risk of significant thromboembolic complications while off AC varied significantly depending on the primary disease process necessitating AC, CONCLUSION: Adequate preoperative correction of coagulation abnormalities and strict regulation of coagulation to avoid supratherapeutic AC is essential. Reintroduction of AC after an intracranial hemorrhage treated without surgery, or after a neurosurgical procedure, particularly an intracranial procedure, can be guided by determining whether the patient is at high, moderate, or low risk for thromboembolic complications. On the basis of experimental studies, the patient's thromboembolic risk, and the experience of other surgeons, we propose therapeutic options for use of AC in neurosurgical patients undergoing intracranial procedures.