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Published on: August 18, 2015
[Antiphospholipid antibody syndrome in pediatric neurosurgery: a hemostasis problem]
R Bocquet1, S Blanot, M D Dautzenberg
1Département d'anesthésie-réanimation chirurgicale, hôpital Necker-Enfants-Malades, Paris, France.
Insights
This case report details a patient with antiphospholipid syndrome who developed heparin-induced thrombocytopenia during neurosurgery. Switching to a heparinoid resolved the condition, highlighting risks of anticoagulation in high-thrombosis-risk patients.
Area of Science:
- Neurology
- Hematology
- Immunology
Background:
- Anticoagulant therapy is crucial for patients with antiphospholipid syndrome (APS) and high thrombosis risk.
- Neurosurgery in such patients requires careful management of anticoagulation to balance bleeding and clotting risks.
Observation:
- An 11-year-old boy with familial APS on anticoagulant therapy underwent surgery for a cerebrovascular malformation.
- Unfractionated heparin (UFH) was used perioperatively, but led to heparin-induced thrombocytopenia (HIT) on day 4.
- Platelet count normalized after switching to danaparoid, a heparinoid, with negative platelet aggregation tests.
Findings:
- Despite negative aggregation tests, ELISA confirmed antibodies against the PF4-heparin complex, indicating HIT.
- The patient experienced a cerebrovascular malformation removal without intraoperative bleeding complications.
- This case highlights the rare but serious complication of HIT in a neurosurgical context.
Implications:
- Anticoagulant therapy, while vital, carries significant risks in neurosurgery, especially for patients with co-existing thrombotic and immunologic disorders.
- Careful monitoring and consideration of alternative anticoagulants like heparinoids are essential in managing HIT during neurosurgery.
- This report underscores the need for vigilance regarding immunologic complications of anticoagulation in high-risk neurosurgical patients.
Abstract:
The case of a 11-year-old boy under anticoagulant therapy for a familial antiphospholipid antibody syndrome (SAAPF), who underwent surgery for a cerebrovascular malformation responsible for an intracerebral haematoma, is reported. Antivitamins K (AVK) were changed for unfractioned heparin (HNF), three days before. Heparin was discontinued two hours prior to surgery to obtain a normal peroperative coagulation. A vascular dural fistula was removed without any haemostatic problem. The neurological status rapidly returned to normal and tomodensitometry at day 1 showed a normal intracranial status. Heparin was readministered at h 16. Thrombocytopenia occurred at day 4 of heparin treatment. The change for a low weight molecular heparinoid, danaparoid (Orgaran), normalized the platelet count. The platelets aggregation tests were negative during thrombopenia. However, the test for antibodies against the PF4-heparin complex with the Elisa technique, was in favour of a heparin induced thrombocytopenia (TIH). In spite of its anecdotic occurrence due to cumulative thrombotic risks from the association of immunologic disorders (TIH and SAAPF), this case report underlines the value but also the risks of anticoagulant therapy in neurosurgery, when patients are at high risk for thrombosis.
