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Is It Safe to Shunt Anticoagulated NPH Patients?

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Anticoagulation and Hemostasis in Neurosurgery

Abstract

Long-term anticoagulation is often considered to be a relative contraindication to shunt surgery for patients with normal pressure hydrocephalus (NPH). While the overall risk of bleeding associated with shunt placement is low, the risk of bleeding in the elderly is increased, particularly with regard to immediate intracerebral hemorrhage or delayed subdural hematoma (SDH) during or after CSF shunting. Furthermore, NPH patients receiving antithrombotic therapy are at a significantly increased risk of hemorrhagic complication compared to patients who are not on antithrombotic therapy. Given the advanced age, gait impairment, and dementia associated with NPH, the bleeding and thrombotic risk may be even higher in NPH than the general population receiving antithrombotic therapy. Therefore, consultation with a hematologist and/or cardiologist is warranted in order to determine which patients can safely suspend antithrombotic therapy prior to surgery versus those who require bridging. Preoperatively, antiplatelet therapy should be stopped at least 7–14 days prior to surgery, whereas warfarin therapy should be stopped at least 5–7 days prior to surgery and/or bridged with a short-acting anticoagulant, in general. Operative considerations that can reduce the risk of hemorrhagic complication include incision of the pia mater prior to ventricular catheter insertion, potential use of intraoperative imaging guidance, and placement of an adjustable and gravity-assisted shunt valve to lower the risk of overdrainage. In the outpatient setting, gradual lowering of the pressure setting should be performed over time until a balance is reached between maximum symptomatic improvement and the onset of symptoms suggestive of low intracranial pressure (e.g., orthostatic headache and dizziness). Postoperatively, the time to resumption of antithrombotic therapy depends on the patients’ individual risk of thrombosis and bleeding as well as radiographic evaluation for intracranial hemorrhage. In summary, patients on long-term antithrombotic therapy can be safely and effectively evaluated and treated for NPH, with the use of appropriate perioperative and postoperative management.

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Authors and Affiliations

  1. Department of Neurosurgery, The Johns Hopkins Hospital, 600 North Wolfe Street, Phipps 126, Baltimore, MD, USA

    Eric W. Sankey B.S., C. Rory Goodwin M.D., Ph.D., Ignacio Jusue-Torres M.D. & Daniele Rigamonti M.D., F.A.C.S., F.A.H.A.

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  1. Eric W. Sankey B.S.
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  2. C. Rory Goodwin M.D., Ph.D.
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  3. Ignacio Jusue-Torres M.D.
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  4. Daniele Rigamonti M.D., F.A.C.S., F.A.H.A.
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Correspondence to Daniele Rigamonti M.D., F.A.C.S., F.A.H.A. .

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  1. Stritch School of Medicine, Loyola University, Maywood, Illinois, USA

    Christopher M. Loftus

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Sankey, E.W., Goodwin, C.R., Jusue-Torres, I., Rigamonti, D. (2016). Is It Safe to Shunt Anticoagulated NPH Patients?. In: Loftus, C. (eds) Anticoagulation and Hemostasis in Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-319-27327-3_28

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  • DOI: https://doi.org/10.1007/978-3-319-27327-3_28

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