Timing of starting anticoagulation following decompressive surgery for cerebral vein and sinus thrombosis: an observational study

Background Anticoagulation is the mainstay acute therapy for cerebral venous thrombosis (CVT). Decompressive surgery is required in a small minority of patients with large parenchymal lesions and impending herniation, which requires a temporary suspension of anticoagulation. Aims The objective of this study was to identify the optimal timing for starting or resuming anticoagulation following decompressive surgery. Methods Data were collected from the Decompressive Surgery for CVT Study 2 (DECOMPRESS2), a prospective multinational cohort observational study of 118 patients with severe CVT treated by decompressive surgery. We assessed the frequency of new hemorrhagic and of venous thrombotic events from admission to discharge in patients who started or resumed anticoagulation <24h (early) and ≥24 (late) following surgery, using propensity score matching and logistic regression. Death and disability were evaluated by the modified Rankin scale (mRS >2) at discharge and at one year follow up and compared between the two groups. Results Of the 90 patients available for analysis, 35 (39%) started or resumed anticoagulation within the first 24 hours after surgery while 55 (61%) did so later than 24 hours. Overall frequency of patients with new hemorrhagic or venous thrombotic events from admission to discharge was 26.7% (24 patients), without crude or adjusted for the propensity score statistically significant difference between the early and late anticoagulation groups (<24h, 11 patients, 31%, vs ≥24h, 13 patients, 24%; OR 0.86; 95% CI 0.24 to 3.04;.X2= 0.33, p= 0.57). The distribution of major hemorrhagic events was also comparable: 8 (23%) bleedings in the <24 hours, and 9 (16%) in the ≥24 hours ((X2= 0.24, p= 0.62). No CVT recurred. Two venous thrombotic events occurred in <24h (6%) and 5 in the ≥24h (9%) group. There was no association between anticoagulation timing and death or dependence (mRS 3-6) at discharge (OR 1.65. 95% CI 0.30 to 9.01, p=0.56), or at one year follow up (OR 2.19, 95% CI 0.78 to 6.10, p=0.14). Conclusions The results of this cohort study suggest that the timing of anticoagulation therapy following decompressive surgery for CVT does not significantly influence the risk of new bleeding or venous thrombotic events or disability.