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Deep brain stimulation in patients on chronic antiplatelet or anticoagulation treatment
Joachim Runge1, Luisa Cassini Ascencao2, Christian Blahak3,4
1Department of Neurosurgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany. runge.joachim@mh-hannover.de.
Insights
Deep brain stimulation (DBS) is feasible for patients on antiplatelet or anticoagulation therapy, with no increased intracranial hemorrhage risk observed. Careful patient selection and perioperative management are key for safe DBS surgery.
Area of Science:
- Neurosurgery
- Cardiology
- Neurology
Background:
- Aging populations present challenges for deep brain stimulation (DBS) candidates with cardiovascular comorbidities requiring antiplatelet or anticoagulation therapy.
- Historically, chronic antiplatelet/anticoagulation treatment was a relative contraindication for DBS due to presumed hemorrhage risks.
- Limited data exists on perioperative management for DBS patients on these medications.
Purpose of the Study:
- To evaluate the risk of intracranial hemorrhage and thromboembolic complications in DBS patients on chronic antiplatelet or anticoagulation treatment.
- To compare complication rates between patients on chronic treatment (managed with pauses or heparin bridging) and those not on treatment.
- To assess the feasibility and safety of DBS surgery in patients requiring perioperative anticoagulation management.
Main Methods:
- Retrospective analysis of 34 patients on chronic treatment undergoing DBS surgery out of 465 functional stereotactic neurosurgery patients.
- Antiplatelet medication was stopped perioperatively; vitamin K antagonists and novel oral anticoagulants (NOACs) were managed with heparin bridging.
- All patients received postoperative stereotactic CT scans and were followed for 1 year.
Main Results:
- Intracranial hemorrhage occurred in 5.9% of DBS surgeries in patients on chronic treatment versus 3.5% in those without (not statistically significant).
- Implantable pulse generator pocket hematomas occurred in 5.9% of surgeries in patients on chronic treatment versus 0.9% in those without.
- Two thromboembolic complications occurred, both in patients not on chronic treatment; no hemorrhagic complications were noted during 1-year follow-up.
Conclusions:
- Deep brain stimulation surgery is feasible for patients on chronic antiplatelet or anticoagulation treatment.
- No increased risk of intracranial hemorrhage was observed in the first year post-DBS surgery for patients on these medications.
- Standardized perioperative management and careful patient selection are crucial for minimizing risks in DBS surgery.
Background:
In the aging society, many patients with movement disorders, pain syndromes, or psychiatric disorders who are candidates for deep brain stimulation (DBS) surgery suffer also from cardiovascular co-morbidities that require chronic antiplatelet or anticoagulation treatment. Because of a presumed increased risk of intracranial hemorrhage during or after surgery and limited knowledge about perioperative management, chronic antiplatelet or anticoagulation treatment often has been considered a relative contraindication for DBS. Here, we evaluate whether or not there is an increased risk for intracranial hemorrhage or thromboembolic complications in patients on chronic treatment (paused for surgery or bridged with subcutaneous heparin) as compared to those without.
Methods:
Out of a series of 465 patients undergoing functional stereotactic neurosurgery, 34 patients were identified who were on chronic treatment before and after receiving DBS. In patients with antiplatelet treatment, medication was stopped in the perioperative period. In patients with vitamin K antagonists or novel oral anticoagulants (NOACs), heparin was used for bridging. All patients had postoperative stereotactic CT scans, and were followed up for 1 year after surgery.
Results:
In patients on chronic antiplatelet or anticoagulation treatment, intracranial hemorrhage occurred in 2/34 (5.9%) DBS surgeries, whereas the rate of intracranial hemorrhage was 15/431 (3.5%) in those without, which was statistically not significant. Implantable pulse generator pocket hematomas were seen in 2/34 (5.9%) surgeries in patients on chronic treatment and in 4/426 (0.9%) without. There were only 2 instances of thromboembolic complications which both occurred in patients without chronic treatment. There were no hemorrhagic complications during follow-up for 1 year.
Conclusions:
DBS surgery in patients on chronic antiplatelet or anticoagulation treatment is feasible. Also, there was no increased risk of hemorrhage in the first year of follow-up after DBS surgery. Appropriate patient selection and standardized perioperative management are necessary to reduce the risk of intracranial hemorrhage and thromboembolic complications.
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