Venous thromboembolism (VTE) in neurosurgery, a literature review. Assessing the evidence for a venous thromboembolism prophylaxis guideline.

BACKGROUND: Neurosurgical patients are at increased risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). Clinical decision making is complicated by the competing risks of VTE versus catastrophic haemorrhage due to pharmacological thromboprophylaxis. Despite the availability of international guidance, practice remains highly variable and often dependent on individual clinician preference. METHODS: A scoping review was conducted using the Patient, Intervention, Comparison, Outcome (PICO) framework to examine VTE risk factors, prophylactic interventions, and bleeding outcomes in neurosurgical patients. Searches were performed across Medline, PubMed, Scopus, CINAHL, Cochrane Library, and Google Scholar, following PRISMA-ScR guidelines. English-language neurosurgical literature and international guidelines were included. Two independent reviewers screened studies. RESULTS: VTE incidence in neurosurgical patients ranges widely, from 0.7% to 34%, with higher rates observed in cranial surgery, malignancy, traumatic brain injury (TBI), prolonged immobility, and patients with prior VTE (Faraoni et al, 2018; Khan et al, 2017; Shani, 2020). Mechanical prophylaxis, particularly intermittent pneumatic compression devices (IPCDs), significantly reduces VTE risk and has a favourable safety profile. Pharmacological prophylaxis with low molecular weight heparin (LMWH) initiated between 24 and 72 h postoperatively, or after confirmation of stable neuroimaging in TBI, consistently reduces VTE incidence without a corresponding increase in major bleeding. Evidence comparing LMWH and unfractionated heparin (UFH) is inconclusive, though guidelines generally favour LMWH. Optimal timing and duration vary by neurosurgical subgroup. CONCLUSION: VTE prophylaxis in neurosurgery requires individualised risk assessment rather than rigid protocols. The balance of evidence supports routine use of mechanical prophylaxis and selective early initiation of pharmacological prophylaxis in most neurosurgical patients commencing 24-72 h post operatively and continuing for 7 to 30 days or until adequate mobilisation. These findings informed the development of a consensus-based neurosurgical VTE prophylaxis guideline across five neurosurgical centres in New Zealand.