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Published on: October 15, 2021
Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical
Maria P Ntalouka1, Alexandros Brotis2, Maria D Karagianni2
1Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Thessaly, Greece. maria.ntalouka@icloud.com.
Insights
Managing antithrombotic medications for brain surgery patients is complex. This review identified and assessed guidelines, finding few with high quality to guide optimal perioperative antithrombotic management.
Area of Science:
- Neurology
- Pharmacology
- Evidence-based Medicine
Background:
- Perioperative management of antithrombotic agents in patients undergoing elective intracranial procedures presents significant clinical challenges.
- Balancing the risks of thromboembolism and bleeding is crucial for patient safety.
Approach:
- A systematic review following PRISMA guidelines was conducted to identify clinical practice guidelines (CPGs) and recommendations (CPRs).
- Literature searches were performed across PubMed, Scopus, and Google Scholar, covering terms related to antithrombotics, intracranial surgery, and perioperative management from 1964 to April 2023.
- The methodological quality and reporting clarity of eligible guidelines were assessed using the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) tool.
Key Points:
- Fourteen sets of guidelines were evaluated for their quality and clarity.
- Guidelines from the European Society of Anaesthesiology and the American College of Chest Physicians demonstrated the highest methodological quality.
- Good interrater agreement (Cohen's Kappa = 0.70) was achieved during the evaluation process.
Conclusions:
- The perioperative management of antithrombotics in intracranial surgery remains challenging due to a lack of high-quality data.
- Uncertainty persists regarding the optimal strategies for managing antithrombotic agents to effectively balance bleeding and thromboembolic risks.
Purpose:
Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity.
Methods:
The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool.
Results:
A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis.
Conclusion:
The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.
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