Subcutaneous heparin for prophylaxis of venous thromboembolism in deep brain stimulation surgery: evidence from a decision analysis.

Overview

abstract

OBJECTIVE: The addition of subcutaneous heparin (SQH) to mechanical prophylaxis for venous thromboembolism (VTE) involves a balance between the benefit of greater protection from VTE and the added risk of intracranial hemorrhage. There is evidence that the hemorrhage risk outweighs the benefits for patients undergoing craniotomy. We investigated the safety of SQH in patients undergoing deep brain stimulation (DBS) surgery. METHODS: A retrospective analysis was performed of all patients with movement disorders (n = 254) undergoing DBS surgery at our institution from 2003 to 2007. Before September 2005, none of the patients undergoing DBS received SQH (non-SQH group) (n = 121). Thereafter, all patients were administered SQH perioperatively (SQH group) (n = 133). All patients wore graduated compression stockings and pneumatic compression boots postoperatively in bed. A postoperative brain magnetic resonance imaging scan was obtained on the day of surgery. RESULTS: Five (3.8%) of 133 SQH patients and 1 (0.8%) of 121 non-SQH patients developed asymptomatic intracranial hemorrhage. None of the SQH patients developed clinically significant VTE, whereas 3 (2.5%) non-SQH patients developed VTE (1 deep venous thrombosis, 2 pulmonary embolisms). Using a decision-analysis model, we have shown that the use of SQH plus mechanical prophylaxis together yielded outcomes at least as good as mechanical prophylaxis alone. CONCLUSION: Our findings suggest that SQH for VTE prophylaxis in patients with movement disorders undergoing DBS surgery is safe. SQH protects against VTE in this patient population and merits further investigation.