Perioperative Management of Anti-Platelet and Anti-Coagulation in Brain Tumor Surgery: An International Survey Study

Introduction: Perioperative management of antithrombotic therapy is a necessary preprocedural consideration for patients prescribed direct oral anticoagulants (DOACs), vitamin K antagonists, or antiplatelet medications. There is a lack of evidence-based guidelines to help inform decision-making in managing antiplatelet and anticoagulation medications in the perioperative period around brain tumor resection. The objective of this study was to provide an example of the heterogeneity in practice and raise awareness for the need to create standardized guidelines for managing these medications.

Methods: A survey was sent to a list of over 800 international neurosurgeons who are members of the Neurosurgery Research Listserv. The survey comprised 70 questions assessing individual practices for managing thromboprophylaxis, antiplatelet medications, and anticoagulation in the perioperative period. The survey was sent via email invitation between March and June of 2021. Respondents’ data were analyzed using chi-square and various nonparametric tests according to the data type and characteristics.

Results: Seventy-two surgeons responded to all questions on the survey or partially completed the survey. There was no difference in medication management pre-operatively or post-operatively when comparing intra and extra-axial tumor resections. Cessation of anti-platelet medications varied between 3-11 days while restart varied between 1-14 days. Preoperative management of vitamin K antagonists varied between indication for use (p < 0.001) while DOAC management did not. Heparin restart post-operatively varied between 1-5 days while DOAC restart post-operatively was reported as a range of 1-14 days.

Conclusion : Survey respondents demonstrate significant heterogeneity in their perioperative management of antiplatelet and anticoagulation medication in brain tumor resection. Guidelines for anticoagulation and antiplatelet medication exist in other surgical subspecialties but not in neurosurgery. This leads to heterogeneity in practice which can be unnecessarily confusing and lead to errors in medication management.