SpringerLink
Log in

Association between external ventricular drain removal or replacement and prophylactic anticoagulation in patients with aneurysmal subarachnoid hemorrhage: a propensity-adjusted analysis

  • Original Article
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Withholding prophylactic anticoagulation from patients with aneurysmal subarachnoid hemorrhage (aSAH) before external ventricular drain (EVD) removal or replacement remains controversial. This study analyzed whether prophylactic anticoagulation was associated with hemorrhagic complications related to EVD removal.

Method

All aSAH patients treated from January 1, 2014, to July 31, 2019, with an EVD placed were retrospectively analyzed. Patients were compared based on the number of prophylactic anticoagulant doses withheld for EVD removal (> 1 vs. ≤ 1). The primary outcome analyzed was deep venous thrombosis (DVT) or pulmonary embolism (PE) after EVD removal. A propensity-adjusted logistic-regression analysis was performed for confounding variables.

Results

A total of 271 patients were analyzed. For EVD removal, > 1 dose was withheld from 116 (42.8%) patients. Six (2.2%) patients had a hemorrhage associated with EVD removal, and 17 (6.3%) patients had a DVT or PE. No significant difference in EVD-related hemorrhage after EVD removal was found between patients with  > 1 versus ≤ 1 dose of anticoagulant withheld (4 of 116 [3.5%] vs. 2 of 155 [1.3%]; p = 0.41) or between those with no doses withheld compared to ≥ 1 dose withheld (1 of 100 [1.0%] vs. 5 of 171 [2.9%]; p = 0.32). After adjustment, withholding > 1 dose of anticoagulant versus ≤ 1 dose was associated with the occurrence of DVT or PE (OR 4.8; 95% CI, 1.5–15.7; p = 0.009).

Conclusions

In aSAH patients with EVDs, withholding > 1 dose of prophylactic anticoagulant for EVD removal was associated with an increased risk of DVT or PE and no reduction in catheter removal–associated hemorrhage.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (France)

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request and institutional review board approval, as applicable.

Abbreviations

aSAH:

Aneurysmal subarachnoid hemorrhage

CCI:

Charlson Comorbidity Index

DVT:

Deep venous thrombosis

EVD:

External ventricular drain

PE:

Pulmonary embolism

POD:

Postoperative day

SQH:

Subcutaneous unfractionated heparin

VTE:

Venous thromboembolism

References

  1. Binz DD, Toussaint LG 3rd, Friedman JA (2009) Hemorrhagic complications of ventriculostomy placement: a meta-analysis. Neurocrit Care 10:253–256

    Article  PubMed  Google Scholar 

  2. Bruder M, Schuss P, Konczalla J, El-Fiki A, Lescher S, Vatter H, Seifert V, Guresir E (2015) Ventriculostomy-related hemorrhage after treatment of acutely ruptured aneurysms: the influence of anticoagulation and antiplatelet treatment. World Neurosurg 84:1653–1659

    Article  PubMed  Google Scholar 

  3. Bruder M, Won SY, Kashefiolasl S, Wagner M, Brawanski N, Dinc N, Seifert V, Konczalla J (2017) Effect of heparin on secondary brain injury in patients with subarachnoid hemorrhage: an additional “H” therapy in vasospasm treatment. J Neurointerv Surg 9:659–663

    Article  PubMed  Google Scholar 

  4. Danish SF, Burnett MG, Stein SC (2004) Prophylaxis for deep venous thrombosis in patients with craniotomies: a review. Neurosurg Focus 17:E2

    Article  PubMed  Google Scholar 

  5. Darze ES, Latado AL, Guimaraes AG, Guedes RA, Santos AB, de Moura SS, Passos LC (2007) Acute pulmonary embolism is an independent predictor of adverse events in severe decompensated heart failure patients. Chest 131:1838–1843

    Article  PubMed  Google Scholar 

  6. Haut ER, Noll K, Efron DT, Berenholz SM, Haider A, Cornwell EE, 3rd, Pronovost PJ (2007) Can increased incidence of deep vein thrombosis (DVT) be used as a marker of quality of care in the absence of standardized screening? The potential effect of surveillance bias on reported DVT rates after trauma. J Trauma 63:1132–1135; discussion 1135–1137

  7. Hoh BL, Nogueira RG, Ledezma CJ, Pryor JC, Ogilvy CS (2005) Safety of heparinization for cerebral aneurysm coiling soon after external ventriculostomy drain placement. Neurosurgery 57:845–849; discussion 845–849

  8. James RF, Kramer DR, Aljuboori ZS, Parikh G, Adams SW, Eaton JC, Abou Al-Shaar H, Badjatia N, Mack WJ, Simard JM (2016) Novel treatments in neuroprotection for aneurysmal subarachnoid hemorrhage. Curr Treat Options Neurol 18:38

    Article  PubMed  Google Scholar 

  9. Kshettry VR, Rosenbaum BP, Seicean A, Kelly ML, Schiltz NK, Weil RJ (2014) Incidence and risk factors associated with in-hospital venous thromboembolism after aneurysmal subarachnoid hemorrhage. J Clin Neurosci 21:282–286

    Article  PubMed  Google Scholar 

  10. Kunz M, Siller S, Nell C, Schniepp R, Dorn F, Huge V, Tonn JC, Pfister HW, Schichor C (2018) Low-dose versus therapeutic range intravenous unfractionated heparin prophylaxis in the treatment of patients with severe aneurysmal subarachnoid hemorrhage after aneurysm occlusion. World Neurosurg 117:e705–e711

    Article  PubMed  Google Scholar 

  11. Laporte S, Liotier J, Bertoletti L, Kleber FX, Pineo GF, Chapelle C, Moulin N, Mismetti P (2011) Individual patient data meta-analysis of enoxaparin vs. unfractionated heparin for venous thromboembolism prevention in medical patients. J Thromb Haemost 9:464–472

    Article  CAS  PubMed  Google Scholar 

  12. Larrew T, Pryor W 3rd, Weinberg J, Webb S, Battenhouse H, Turk AS, Chaudry I, Spiotta A, Turner R (2015) Aneurysmal subarachnoid hemorrhage: a statewide assessment of outcome based on risk factors, aneurysm characteristics, and geo-demography. J Neurointerv Surg 7:855–860

    Article  PubMed  Google Scholar 

  13. Malato A, Dentali F, Siragusa S, Fabbiano F, Kagoma Y, Boddi M, Gensini GF, Peris A, Crowther M, Napolitano M (2015) The impact of deep vein thrombosis in critically ill patients: a meta-analysis of major clinical outcomes. Blood Transfus 13:559–568

    PubMed  PubMed Central  Google Scholar 

  14. Pierce CA, Haut ER, Kardooni S, Chang DC, Efron DT, Haider A, Pronovost PJ, Cornwell EE, 3rd (2008) Surveillance bias and deep vein thrombosis in the national trauma data bank: the more we look, the more we find. J Trauma 64:932–936; discussion 936–937

  15. Qureshi AI, Suri MF, Nasar A, Kirmani JF, Divani AA, He W, Hopkins LN (2005) Trends in hospitalization and mortality for subarachnoid hemorrhage and unruptured aneurysms in the United States. Neurosurgery 57:1–8; discussion 1–8

  16. Ray WZ, Strom RG, Blackburn SL, Ashley WW, Sicard GA, Rich KM (2009) Incidence of deep venous thrombosis after subarachnoid hemorrhage. J Neurosurg 110:1010–1014

    Article  PubMed  Google Scholar 

  17. Simard JM, Schreibman D, Aldrich EF, Stallmeyer B, Le B, James RF, Beaty N (2010) Unfractionated heparin: multitargeted therapy for delayed neurological deficits induced by subarachnoid hemorrhage. Neurocrit Care 13:439–449

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Tanweer O, Boah A, Huang PP (2013) Risks for hemorrhagic complications after placement of external ventricular drains with early chemical prophylaxis against venous thromboembolisms. J Neurosurg 119:1309–1313

    Article  PubMed  Google Scholar 

  19. Vance AZ, Jayaraman MV, Dubel GJ, Doberstein CE, Haas RA (2009) Safety of intravenous heparin administration after endovascular treatment for ruptured intracranial aneurysms. J Neurointerv Surg 1:136–141

    Article  CAS  PubMed  Google Scholar 

  20. Zachariah J, Snyder KA, Graffeo CS, Khanal DR, Lanzino G, Wijdicks EF, Rabinstein AA (2016) Risk of ventriculostomy-associated hemorrhage in patients with aneurysmal subarachnoid hemorrhage treated with anticoagulant thromboprophylaxis. Neurocrit Care 25:224–229

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

Author information

Author notes

  1. Joshua S. Catapano and Stefan W. Koester contributed equally to this work.

Authors and Affiliations

  1. Department of Neurosurgery, c/o Neuroscience Publications, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA

    Joshua S. Catapano, Stefan W. Koester, Parth P. Parikh, Kavelin Rumalla, Henry O. Stonnington, Rohin Singh, Ethan A. Winkler, Christopher S. Graffeo, Robert F. Rudy, Visish M. Srinivasan, Ruchira M. Jha, Ashutosh P. Jadhav, Felipe C. Albuquerque, Michael T. Lawton & Andrew F. Ducruet

Authors
  1. Joshua S. Catapano
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stefan W. Koester
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Parth P. Parikh
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kavelin Rumalla
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Henry O. Stonnington
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rohin Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ethan A. Winkler
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Christopher S. Graffeo
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Robert F. Rudy
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Visish M. Srinivasan
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Ruchira M. Jha
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Ashutosh P. Jadhav
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Felipe C. Albuquerque
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Michael T. Lawton
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Andrew F. Ducruet
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Joshua S. Catapano, Stefan W. Koester, Parth P. Parikh, Kavelin Rumalla, Henry O. Stonnington, and Rohin Singh. The first draft of the manuscript was written by the aforementioned authors and all authors commented on subsequent versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Andrew F. Ducruet.

Ethics declarations

Ethical approval

This retrospective cohort study was approved by the St. Joseph’s Hospital and Medical Center Institutional Review Board (Phoenix, Arizona).

Informed consent

Informed consent for the study was waived due to the low risk to patients and the study’s retrospective nature.

Conflict of interest

The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this manuscript. No parts of this manuscript have been previously published or presented.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Catapano, J.S., Koester, S.W., Parikh, P.P. et al. Association between external ventricular drain removal or replacement and prophylactic anticoagulation in patients with aneurysmal subarachnoid hemorrhage: a propensity-adjusted analysis. Acta Neurochir 165, 1841–1846 (2023). https://doi.org/10.1007/s00701-023-05651-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-023-05651-1

Keywords

Search

Navigation