Abstract
Objective
The use of antiplatelet or anticoagulants has previously been shown to increase hemorrhagic complications of ventricular catheterization. Although heparin use 24 h after ventriculostomy appears safe, the safety of heparin immediately (within 4 h) after ventriculostomy is unknown. The objective of this study was to assess the safety of heparin immediately (within 4 h) after ventriculostomy in subarachnoid hemorrhage (SAH) patients undergoing endovascular treatment.
Patients and Methods
This is a retrospective cohort study of 46 patients with aneurysmal SAH secondary to aneurysm rupture who required ventriculostomy. Post-ventriculostomy imaging was carefully reviewed for tract hemorrhaging. Timing of heparinization was noted. Early heparinization was within 4 h after ventriculostomy, and intermediate heparinization was between 4 and 24 h after ventriculostomy.
Results
Overall, the tract hemorrhage rate was 26.1% for the study cohort—mostly grade I tract hemorrhages—consistent with the existing literature. The tract hemorrhage rate in the early (<4 h) heparin group was a remarkable 58.8%. The hemorrhages were also notably larger in the early (<4 h) heparin group.
Conclusion
Although heparin appears to be safe after 4 h, immediate heparinization (within 4 h) after ventriculostomy significantly increases the odds of tract hemorrhage. Additional time should be afforded between ventriculostomy and heparinization to avoid potentially devastating external ventricular drain tract hemorrhage. It is advisable to wait a sufficient time (at least 4 h) after ventriculostomy before embarking on endovascular treatment of ruptured aneurysms.
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Abbreviations
- DVT:
-
Deep venous thrombosis
- EVD:
-
External ventricular drain
- SAH:
-
Subarachnoid hemorrhage
References
Muirhead WR, Basu S. Trajectories for frontal external ventricular drain placement: virtual cannulation of adults with acute hydrocephalus. Br J Neurosurg. 2012;26:710–6.
Anderson RC, Kan P, Klimo P, Brockmeyer DL, Walker ML, Kestle JR. Complications of intracranial pressure monitoring in children with head trauma. J Neurosurg. 2004;101:53–8.
Binz DD, Toussaint LG 3rd, Friedman JA. Hemorrhagic complications of ventriculostomy placement: a meta-analysis. Neurocrit Care. 2009;10:253–6.
Gardner PA, Engh J, Atteberry D, Moossy JJ. Hemorrhage rates after external ventricular drain placement. J Neurosurg. 2009;110:1021–5.
Maniker AH, Vaynman AY, Karimi RJ, Sabit AO, Holland B. Hemorrhagic complications of external ventricular drainage. Neurosurgery. 2006;59:ONS419–24; (discussion ONS24–5).
Sussman ES, Kellner CP, Nelson E, et al. Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage. J Neurosurg. 2014;120:931–6.
Bruder M, Schuss P, Konczalla J, et al. Ventriculostomy related hemorrhage after treatment of acutely ruptured aneurysms: the influence of anticoagulation and antiplatelet treatment. World Neurosurg. 2015;84:1653–9.
Hoh BL, Nogueira RG, Ledezma CJ, Pryor JC, Ogilvy CS. Safety of heparinization for cerebral aneurysm coiling soon after external ventriculostomy drain placement. Neurosurgery. 2005;57:845–9 (discussion-9).
Amenta PS, Dalyai RT, Kung D, et al. Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: experience in 65 patients. Neurosurgery. 2012;70:1415–29 (discussion 29).
Chung J, Lim YC, Suh SH, et al. Stent-assisted coil embolization of ruptured wide-necked aneurysms in the acute period: incidence of and risk factors for periprocedural complications. J Neurosurg. 2014;121:4–11.
Kung DK, Policeni BA, Capuano AW, et al. Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling. J Neurosurg. 2011;114:1021–7.
Sims-Williams HP, Weinberg D, Jadun CK, Brydon HL. Ventriculostomy associated haemorrhage: a complication of anti-platelet therapy during coiling. Br J Neurosurg. 2014;28:782–4.
Sweeney JM, Vasan R, van Loveren HR, Youssef AS, Agazzi S. Catheter fixation and ligation: a simple technique for ventriculostomy management following endovascular stenting. J Neurosurg. 2013;118:1009–13.
Tanweer O, Boah A, Huang PP. Risks for hemorrhagic complications after placement of external ventricular drains with early chemical prophylaxis against venous thromboembolisms. J Neurosurg. 2013;119:1309–13.
de Oliveira Manoel AL, Turkel-Parrella D, Germans M, et al. Safety of early pharmacological thromboprophylaxis after subarachnoid hemorrhage. Can J Neurol Sci Le Journal Canadien des Sciences Neurologiques. 2014;41:554–61.
Ko JK, Cha SH, Choi BK, Lee JI, Yun EY, Choi CH. Hemorrhage rates associated with two methods of ventriculostomy: external ventricular drainage versus ventriculoperitoneal shunt procedure. Neurol Med Chir. 2014;54:545–51.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–81.
Ehtisham A, Taylor S, Bayless L, Klein MW, Janzen JM. Placement of external ventricular drains and intracranial pressure monitors by neurointensivists. Neurocrit Care. 2009;10:241–7.
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Gard, A.P., Sayles, B.D., Robbins, J.W. et al. Hemorrhage Rate After External Ventricular Drain Placement in Subarachnoid Hemorrhage: Time to Heparin Administration. Neurocrit Care 27, 350–355 (2017). https://doi.org/10.1007/s12028-017-0417-4
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DOI: https://doi.org/10.1007/s12028-017-0417-4