Venous Thromboembolism Prophylaxis in Elective Neurosurgery: A Survey of Board-Certified Neurosurgeons in the United States and Updated Literature Review.

BACKGROUND: Venous thromboembolism (VTE) remains the single most important preventable cause of morbidity and mortality following neurosurgical procedures, with an incidence of approximately 16%. In the absence of stringent guidelines, the variation in current practice patterns could be considerable and was the underlying basis for this study. OBJECTIVES: Our objective is to evaluate the modality of thromboprophylaxis used by neurosurgeons. METHODS: In line with "CHERRIES" (Checklist for Reporting Results of Internet E-Surveys) guidelines, an online survey regarding postoperative VTE prophylaxis following elective neurosurgical procedures was created using Google Forms and distributed to 1500 board-certified neurosurgeons in the United States. RESULTS: A total of 370 board-certified neurosurgeons (24.7%) responded to the survey. Sequential compression device was the only primary method of thromboprophylaxis used by 27.2% and 26.5% of respondents after elective craniotomy for tumor resection and spine surgery, respectively. Of the chemical prophylaxis, subcutaneous heparin 5000 U every 8 hours was the most commonly used medication followed by enoxaparin 40 mg daily. Most responders were comfortable starting chemical prophylaxis on postoperative day 1, followed by day 2 and day 3 in both types of surgeries. The mean postoperative time of chemical prophylaxis initiation was significantly more delayed by respondents with longer years in practice. CONCLUSIONS: This study highlights the variation in practice between neurosurgeons in managing postoperative VTE prophylaxis after elective spine and cranial surgeries. In lieu of this variation, our results showed that most neurosurgeons are comfortable starting chemical prophylaxis as soon as postoperative day 1 following both types of procedures.

The Reproducibility of Cerebrovascular Randomized Controlled Trials.

BACKGROUND: Numerous randomized controlled trials (RCTs) relevant to the cerebrovascular field have been performed. The fragility index was recently developed to complement the P value and measure the robustness and reproducibility of clinical findings of RCTs. OBJECTIVE: In this study, we evaluate the fragility index for key surgical and endovascular cerebrovascular RCTs and propose a novel RCT classification system based on the fragility index. METHODS: Cerebrovascular RCTs reported between 2000 and 2018 were reviewed. Six key areas were specifically targeted in relation to stroke, carotid stenosis, cerebral aneurysms, and subarachnoid hemorrhage. The correlation between fragility index, number of patients lost to follow-up, and fragility quotient were evaluated to propose a classification system for the robustness of the studies. RESULTS: A total of 20 RCTs that reported significant differences between both study groups in terms of the primary outcome were included. The median fragility index for the trials was 5.5. An additional 30 randomly selected RCTs were added to propose a classification system with high reliability. The difference between the number of patients lost to follow-up and fragility index inversely correlated with the fragility quotient and was used to divide the robustness of the RCTs into 3 classes reflecting the reproducibility of the trial. CONCLUSIONS: Neurosurgeons and neurointerventionalists should exercise caution with interpreting the results of cerebrovascular RCTs, especially when the sample size and events numbers are small and there is a high number of patients who were lost to follow-up, as quantitatively identified using the proposed classification system.