From the Guidelines
Preoperative neurosurgical coagulation profile preparation should prioritize the discontinuation of anticoagulant and antiplatelet medications to minimize bleeding risks, with direct oral anticoagulants (DOACs) stopped 5 days before surgery and antiplatelet agents like aspirin and clopidogrel discontinued 7-9 days preoperatively for intracranial neurosurgery, as recommended by the French Working Group on Perioperative Hemostasis (GIHP) 1. To prepare a patient for neurosurgery, several key steps must be taken to assess and manage their coagulation profile. This includes:
- Performing a complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count within 24-48 hours before surgery.
- Ensuring INR is below 1.4, platelets are above 100,000/μL, and aPTT is within the normal range.
- Discontinuing anticoagulant medications like warfarin 5-7 days before surgery with INR monitoring.
- Stopping DOACs such as apixaban, rivaroxaban, and dabigatran 5 days before surgery, considering renal function, as suggested by the GIHP guidelines 1.
- Discontinuing antiplatelet agents including aspirin and clopidogrel 7-9 days preoperatively for intracranial neurosurgery, following the proposals from the French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Thrombosis and Haemostasis (GFHT) 1. For patients with high thrombotic risk, bridging therapy with low-molecular-weight heparin (LMWH) like enoxaparin may be considered, stopping 24 hours before surgery. Additionally, interventions such as vitamin K to reverse warfarin effects, prothrombin complex concentrate for rapid reversal in emergencies, fresh frozen plasma to correct coagulopathy, and desmopressin to improve platelet function in selected cases may be critical in managing bleeding risks during neurosurgical procedures 1.
From the Research
Preoperative Neurosurgical Coagulation Profile Preparation
To prepare a patient for neurosurgery, it is essential to assess and manage their coagulation profile to minimize the risk of bleeding complications. The following points highlight the key considerations:
- Preoperative correction of coagulation abnormalities is crucial to prevent postoperative bleeding complications 2.
- The value of routine preoperative prothrombin time (PT) screening in elective neurosurgical procedures is limited, especially in patients with a normal medical history 3.
- Antihemostatic and anticoagulant drugs can increase the risk of perioperative bleeding, while an increased risk of venous thromboembolism and hypercoagulative state can occur after elective and emergency neurosurgery 4.
- Low-molecular-weight heparins (LMWH) are a type of anticoagulant that can be used to prevent venous thromboembolism, with predictable pharmacokinetics and increased bioavailability 5.
Coagulation Management Strategies
Effective coagulation management strategies include:
- Balancing the risk between thrombosis and bleeding by being familiar with perioperative changes in coagulation and recent management guidelines for anticoagulated patients undergoing neurosurgical procedures 4.
- Using a low-molecular weight heparin-calibrated anti-factor Xa assay to estimate the concentration of direct oral anticoagulants (DOACs) such as apixaban and rivaroxaban in the acute setting 6.
- Considering the patient's thromboembolic risk and the experience of other surgeons when reintroducing anticoagulation after an intracranial hemorrhage or neurosurgical procedure 2.
Key Considerations for Patient Care
When preparing a patient for neurosurgery, the following key considerations should be taken into account:
- Close postoperative PT control is necessary in every neurosurgical patient 3.
- Better tests need to be developed to identify patients who are prone to hemorrhagic complications 3.
- The patient's medical history and current medications should be carefully evaluated to assess their risk of bleeding complications and guide coagulation management decisions 2, 4.