Use of thrombin-based hemostatic matrix during meningioma resection: a potential risk factor for perioperative thromboembolic events.

OBJECTIVE: Hemostatic agents are widely used in patients undergoing intracranial tumor resection to facilitate local hemostasis. We hypothesized that systemic activation of the clotting cascade after local application of hemostatic agents may result in unintended thromboembolic events, including deep venous thrombosis (DVT) and pulmonary embolism (PE). We performed a retrospective analysis to identify potential associations between hemostatic agent use and DVT/PE.

METHODS: A single-institution review of patients undergoing surgical resection of cranial meningiomas was performed. Patient demographics including gender and BMI, procedure duration, estimated blood loss (EBL), tumor pathology, use of hemostatic matrix, and the presence of DVT/PE within 14 days of surgery were collected from the medical record.

RESULTS: A total of 467 patients underwent a craniotomy for meningioma from 2009 to 2012. There were 331 women and 136 men with a mean age of 58 ± 14 years (range 18-92) and mean BMI of 28 ± 6. Tumor pathology included 359 grade I, 77 grade II, and 31 grade III tumors. There were 12 patients (2.6%) with thromboembolic events. Age (p=0.66), gender (p=0.33), EBL (p=0.99), and procedure duration (p=0.17) were not associated with an increased incidence of DVT/PE. Use of DVT prophylaxis initiated 72 h after surgery did not significantly alter the incidence of DVT/PE (p=0.20). Body mass index (p=0.04) and tumor grade (p=0.05) were associated with increased incidence of DVT/PE. Patients receiving greater than 10 ml of a hemostatic agent intraoperatively had an increased incidence of DVT/PE (p=0.02). In a multivariate model, both BMI (OR=1.07, 95% CI: 1.00-1.15, p=0.048) and use of more than 10 ml of hemostatic agent (OR=8.03, CI: 1.02-63.40, p=0.048) were found to be significantly associated with the risk of DVT/PE.

CONCLUSION: Hemostatic agents are valuable tools in modern neurosurgery, however their use may be associated with an increased risk of DVT/PE in patients undergoing meningioma resection. This finding provides the impetus for more definitive clinical and laboratory studies to characterize the biology of this association and helps identify patients at increased risk for thromboembolism. This study also affirms the association between high BMI and the risk of thromboembolism. Interestingly the use of prophylactic anticoagulation after surgery did not decrease the incidence of DVT/PE.