Sellar and parasellar tumor removal without discontinuing antithrombotic therapy

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OBJECT

Treatment with dual antiplatelet agents associated with coronary stenting procedures and long-term anticoagulant therapy is increasingly common, but the treatment carries risks during surgical procedures. Evidence-based recommendations have proposed discontinuation of antithrombotic treatment or introduction of bridging therapy in some procedures less invasive and with lower risk of bleeding. However, neurosurgical procedures without discontinuation of antithrombotic treatment and perioperative management have received little investigation.

METHODS

Between October 2008 and January 2014, 15 consecutive patients (11 males and 4 females; age range 51–75 years [mean 68.2 years]), with sellar and parasellar tumors were treated through the transsphenoidal approach without discontinuation of antithrombotic therapy. Clinical data were compared with another 15 patients, who underwent transsphenoidal surgeries without preoperative antithrombotic therapy.

RESULTS

Gross-total removal of the tumor or total aspiration of the content of Rathke's cleft cyst was achieved in 13 patients, and subtotal removal was achieved in 1 patient with a small remnant in the cavernous sinus. No difference was found in intraoperative bleeding between the antithrombotic agent group and the control group (mean 255 ml vs 215 ml, Mann-Whitney U-test, p = 0.547), and no patient required transfusion. No difference was found in operation time between the antithrombotic agent group and the control group (167.8 minutes vs 150.0 minutes, Mann-Whitney U-test, p = 0.262). All patients were discharged on postoperative Day 12 without neurological deficits.

CONCLUSIONS

The present study suggests that discontinuation of antithrombotic therapy may be unnecessary before the typical transsphenoidal surgery. Large randomized clinical trials at multiple centers are needed to confirm these findings.

ABBREVIATIONPT-INR = prothrombin time; international normalized ratio.

Abstract

OBJECT

Treatment with dual antiplatelet agents associated with coronary stenting procedures and long-term anticoagulant therapy is increasingly common, but the treatment carries risks during surgical procedures. Evidence-based recommendations have proposed discontinuation of antithrombotic treatment or introduction of bridging therapy in some procedures less invasive and with lower risk of bleeding. However, neurosurgical procedures without discontinuation of antithrombotic treatment and perioperative management have received little investigation.

METHODS

Between October 2008 and January 2014, 15 consecutive patients (11 males and 4 females; age range 51–75 years [mean 68.2 years]), with sellar and parasellar tumors were treated through the transsphenoidal approach without discontinuation of antithrombotic therapy. Clinical data were compared with another 15 patients, who underwent transsphenoidal surgeries without preoperative antithrombotic therapy.

RESULTS

Gross-total removal of the tumor or total aspiration of the content of Rathke's cleft cyst was achieved in 13 patients, and subtotal removal was achieved in 1 patient with a small remnant in the cavernous sinus. No difference was found in intraoperative bleeding between the antithrombotic agent group and the control group (mean 255 ml vs 215 ml, Mann-Whitney U-test, p = 0.547), and no patient required transfusion. No difference was found in operation time between the antithrombotic agent group and the control group (167.8 minutes vs 150.0 minutes, Mann-Whitney U-test, p = 0.262). All patients were discharged on postoperative Day 12 without neurological deficits.

CONCLUSIONS

The present study suggests that discontinuation of antithrombotic therapy may be unnecessary before the typical transsphenoidal surgery. Large randomized clinical trials at multiple centers are needed to confirm these findings.

Long-term anticoagulant therapy is currently administered to more than 6 million patients for the treatment of atrial fibrillation, deep venous thrombosis, various valve diseases, and malignancy-related syndromes.4,5 In addition, recent advances in coronary stenting procedures have rapidly increased the need for treatment with dual antiplatelet agents.5 However, about 10% of these patients will undergo invasive procedures every year, which will require temporary discontinuation of the antithrombotic therapy or some bridging therapy.4,5,21,28 Evidence-based recommendations have been proposed to deal with this complicated countermeasure in some less invasive procedures with lower risk of bleeding, such as dental procedures or cataract operations.1–3,6–19,21–25,29,30,32–38 However, procedures without discontinuation of antithrombotic treatment have received little attention,39 and the perioperative period in neurosurgical procedures has also been less well studied.20,26,27,31,40–42

The present clinical study retrospectively analyzed a series of transsphenoidal surgeries performed without discontinuation of antithrombotic therapy for comparison with the same number of transsphenoidal surgeries performed in the absence of antithrombotic therapy.

Methods

Between October 2008 and January 2014, 15 consecutive patients (11 males and 4 females; age range 51–75 years [mean 68.2 years]) with sellar and parasellar tumors were treated via a transsphenoidal approach by a single surgeon (Y.O.), accounting for 2.51% of all transsphenoidal operations during the same period. The histological diagnoses were pituitary adenoma (n = 9), Rathke's cleft cyst (n = 4), clival chordoma (n = 1), and biopsy of skull base pachymeningitis (n = 1). Eleven patients were treated with antiplatelet agents and 4 with anticoagulant agents. The prothrombin time–international normalized ratio (PT-INR) was measured preoperatively before administering anticoagulant agents, which verified that all PT-INRs were within the required limits (Table 1). The patients continued to take antithrombotic agents until the morning of surgery, and, after verification of the absence of ischemic and/or hemorrhagic complications on the morning of postoperative Day 1, administration of antithrombotic agents was restarted. All operations were performed via sublabial mucosal incisions, and the closest attention was paid to preserve the arachnoid plane at the top of the lesions in expectation of postprocedural hemostasis by compressive pressure of CSF spaces. Extended transsphenoidal surgeries through the subarachnoid spaces and giant pituitary adenomas with a maximum diameter larger than 40 mm were excluded due to the presumptive high risk of after-bleeding. Clinical data were compared with the data of 15 patients who underwent transsphenoidal surgery without preoperative antithrombotic therapy between December 2013 and January 2014. The surgical policy was explained preoperatively to the patients, and written informed consent was obtained. The overall study design was approved by the ethics committee of Kohnan Hospital. Statistical comparisons used Mini Statmate software (ATMS Co., Ltd.), and p values < 0.05 were regarded as significant.

TABLE 1

Profiles of patients undergoing antithrombotic therapy

Case No.Age (yrs), SexHistologyAntithrombotic AgentReasonRemarks
174, MAtypical adenomaAspirin 100 mgACA stenosisOpening of CS
267, MRathke's cleft cystAspirin 100 mgCoronary stent
375, MPlurihormonal adenomaAspirin 100 mgAnginaOpening of CS
471, FRathke's cleft cystClopidogrel 25 mgMCA stenosis
572, MRathke's cleft cystAspirin 81 mgAMI
675, FAcromegalyPT-INR 1.34Paroxysmal AF
762, MPlurihormonal adenomaAspirin 100 mgAngina
866, MRathke's cleft cystAspirin 100 mgCoronary stent
Ticlopidine 200 mgY graft & FF bypass
967, FGonadotroph cell adenomaCilostazol 200 mgAortic dissection
1072, MMixed GH & PRL adenomaAspirin 100 mgRepeat anginaSuspended clopidogrel
1151, MPachymeningitisPT-INR 2.01AVR, AV block (3)Temporary pacemaker
1269, MPlurihormonal adenomaAspirin 100 mgCoronary stentOpening of CS
1370, MNull cell adenomaAspirin 100 mgAngina
1471, FCorticotroph cell adenomaPT-INR 1.55DVT
1561, MChordomaPT-INR 1.95Paroxysmal AFOpening of CS

ACA = anterior cerebral artery; AF = atrial fibrillation; AMI = acute myocardial infarction; AV = atrioventricular; AVR = aortic valve replacement; CS = cavernous sinus; DVT = deep venous thrombosis; FF = femoral-femoral; GH = growth hormone; MCA = middle cerebral artery; PRL = prolactin; PT-INR = prothrombin time-international normalized ratio.

Results

Gross-total removal of the tumor or total aspiration of the content of the Rathke's cleft cyst was achieved in 13 patients, and subtotal removal was achieved in 1 patient with a small remnant in the cavernous sinus. Aggressive removal was suspended in 1 patient because intraoperative histological examination had revealed pachymeningitis. Head CT scanning performed the morning of postoperative Day 1 revealed that most cavities of the sellae were occupied with CSF, so-called empty sellae. No patient experienced massive abnormal bleeding throughout the hospital course. Comparison of the antithrombotic agent group and the control group found no difference in preoperative tumor volume (antithrombotic agent group vs control: 2.45 ml vs 3.18 ml, p = 0.48), but patients were older in the antithrombotic agent group (63.32 years vs 57.73 years, p = 0.029). Opening of the ipsilateral cavernous sinus occurred in 4 patients in the antithrombotic agent group, but hemostasis was achieved in all patients with common techniques, such as compression with cotton flakes and/or point-by-point coagulation. In the antithrombotic agent group, bleeding varied from 100 ml to 485 ml (mean 255 ml), and no patient required transfusion, even after open cavernous sinus surgeries. Comparison of the antithrombotic agent group and the control group found no difference in intraoperative bleeding (255 ml vs 215 ml, Mann-Whitney U-test, p = 0.547). Operation time varied in the antithrombotic agent group from 114 minutes to 241 minutes (mean 167.8 minutes). Comparison of the antithrombotic agent group and the control group found no difference in operation time (167.8 minutes vs 150.0 minutes, Mann-Whitney U-test, p = 0.262) (Tables 2 and 3). All patients were discharged on postoperative Day 12 without neurological deficits.

TABLE 2

Results of surgery with antithrombotic therapy

Case No.HistologyVol (ml)Blood Loss (ml)Operation Time (mins)Removal Rate (%)
1Atypical adenoma1.89130164100
2Rathke's cleft cyst0.86230114100
3Plurihormonal adenoma1.16125149100
4Rathke's cleft cyst0.94485162100
5Rathke's cleft cyst0.09100137100
6Acromegaly3.04150127100
7Plurihormonal adenoma4.39290228100
8Rathke's cleft cyst0.5125123100
9Gonadotroph cell adenoma0.6300144100
10Mixed GH & PRL adenoma5.46460171100
11Pachymeningitis115241Biopsy
12Plurihormonal adenoma9.0142523796
13Null cell adenoma2.89205131100
14Corticotroph cell adenoma0.01290195100
15Chordoma3.4400194100
TABLE 3

Results of surgery without antithrombotic therapy

Case No.Age (yrs), SexPathologyVol (ml)Blood Loss (ml)Operation Time (mins)Removal Rate (%)
1628, FLactotroph cell adenoma0.05135156100
1754, FAcromegaly4.8224519998
1858, MNonfunctioning1.89185147100
1946, MPlurihormonal adenoma3.56150164100
2071, FPlurihormonal adenoma2.28163157100
2141, MPituitary apoplexy2.57134119100
2265, FPlurihormonal adenoma0.91353145100
2366, MPlurihormonal adenoma3.23345120100
2456, FPlurihormonal adenoma0.84180123100
2562, FMixed GH & PRL adenoma0.32100119100
2670, MPlurihormonal adenoma5.86350191100
2781, MPlurihormonal adenoma3.63120155100
2881, MSomatotroph cell adenoma11.0253519095
2955, FPlurihormonal adenoma6.55135148100
3032, FPlurihormonal adenoma0.19100116100

Discussion

The risk of thrombosis has been estimated for some systemic diseases or conditions.4,5,28 Recent venous thrombosis (within 1 month), repeated arteriovenous thrombophilia, and mitral valve disease carry higher risks of thrombosis, whereas old venous thrombosis (> 3 months) and nonvalvular atrial fibrillation involve lower risks of thrombosis.21 Invasive procedures also involve the risk of bleeding in patients receiving antithrombotic therapy. Orthopedic hip procedures and colon polypectomy have higher risks of bleeding, whereas dental procedures, cataract surgery, dermatological procedures, and surgery for carpal tunnel syndrome have lower risks of bleeding.4 The factors of thrombogenesis and fibrinolysis have been specifically considered in some invasive procedures, resulting in evidence-based recommendations for discontinuation of antithrombotic therapy or introduction of bridging therapy.4,5,21,28 A large randomized study was reported recently in patients receiving or not receiving aspirin therapy who underwent noncardiac surgery. The study revealed that there was not an increase in cardiac or cerebrovascular events in the patients who discontinued the antiplatelet therapy compared with those who did not, although there was a slight increase in the amount of hemorrhage in the group that stayed on antiplatelet therapy.12 However, in this study more than two-thirds of the patients had received bridging anticoagulant therapy, so the true result with or without discontinuation of antiplatelet therapy in perioperative period remains unsolved.

Very few clinical studies have considered perioperative management of neurosurgical patients receiving antithrombotic therapy except for antiplatelet therapies incorporated in intravascular treatments.20,26,27,31,42 Temporary discontinuation of antithrombotic therapy or introduction of bridging therapy is rarely mentioned in cases of internal carotid artery dissection,40 as is placement of cutaneousventricular drainage for patients after intravascular treatment.41 However, these cases do not provide a high level of medical evidence.

The present cohort study was performed at a single institution and by a single surgeon. The protocol was simple, as neither discontinuation of antithrombotic therapy nor introduction of bridging therapy was required. Therefore, the treatment and control groups were easily compared. However, the true implications cannot be fully clarified, and validation of this protocol is limited only to extraarachnoid, typical transsphenoidal surgeries. Large randomized clinical trials at multiple centers are essential to recommend standardization of this management for patients receiving antithrombotic therapy. Although patients receiving antithrombotic therapy should only undergo transsphenoidal surgery when absolutely necessary, various types of procedures should be investigated to establish a high level of medical evidence about this increasing problem in the neurosurgical field.

Conclusions

Transsphenoidal surgeries were performed in 15 patients without discontinuation of antithrombotic therapy. No patient required transfusion, and intraoperative bleeding, operation time, and tumor removal rate showed no significant differences between these patients and the control group. The present study suggests that discontinuation of antithrombotic therapy may be unnecessary before the typical transsphenoidal surgery. Large randomized clinical trials are needed to establish validation of this procedure.

Author Contributions

Conception and design: Ogawa. Acquisition of data: Ogawa. Analysis and interpretation of data: Ogawa. Drafting the article: Ogawa. Critically revising the article: both authors. Reviewed submitted version of manuscript: Tominaga. Approved the final version of the manuscript on behalf of both authors: Ogawa. Statistical analysis: Ogawa. Administrative/technical/material support: Ogawa. Study supervision: Tominaga.

References

  • 1

    Ah-Weng ANatarajan SVelangi SLangtry JA: Preoperative monitoring of warfarin in cutaneous surgery. Br J Dermatol 149:3863892003

  • 2

    Alam MGoldberg LH: Serious adverse vascular events associated with perioperative interruption of antiplatelet and anticoagulant therapy. Dermatol Surg 28:9929982002

  • 3

    Alcalay J: Cutaneous surgery in patients receiving warfarin therapy. Dermatol Surg 27:7567582001

  • 4

    Armstrong MJGronseth GAnderson DCBiller JCucchiara BDafer R: Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 80:206520692013

  • 5

    Baron THKamath PSMcBane RD: Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 368:211321242013

  • 6

    Billingsley EMMaloney ME: Intraoperative and postoperative bleeding problem in patients taking warfarin, aspirin, and nonsteroidal anti-inflammatory agents. A prospective study. Dermatol Surg 23:3813831997

  • 7

    Cannon PDDharmar VT: Minor oral surgical procedures in patients on oral anticoagulants—a controlled study. Aust Dent J 48:1151182003

  • 8

    Carrel TPKlingenmann WMohacsi PJBerdat PAlthaus U: Perioperative bleeding and thromboembolic risk during non-cardiac surgery in patients with mechanical prosthetic heart valves: an institutional review. J Heart Valve Dis 8:3923981999

  • 9

    Carter KMiller KM: Phacoemulsification and lens implantation in patients treated with aspirin or warfarin. J Cataract Refract Surg 24:136113641998

  • 10

    Custer PLTrinkaus KM: Hemorrhagic complications of oculoplastic surgery. Ophthal Plast Reconstr Surg 18:4094152002

  • 11

    Devani PLavery KMHowell CJ: Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary?. Br J Oral Maxillofac Surg 36:1071111998

  • 12

    Devereaux PJMrkobrada MSessler DILeslie KAlonso-Coello PKurz A: Aspirin in patients undergoing non-cardiac surgery. N Engl J Med 370:149415032014

  • 13

    Dunn ASTurpie AG: Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med 163:9019082003

  • 14

    Evans ILSayers MSGibbons AJPrice GSnooks HSugar AW: Can warfarin be continued during dental extraction? Results of a randomized controlled trial. Br J Oral Maxillofac Surg 40:2482522002

  • 15

    Gainey SPRobertson DMFay WIlstrup D: Ocular surgery on patients receiving long-term warfarin therapy. Am J Ophthalmol 108:1421461989

  • 16

    Hall DLSteen WH JrDrummond JWByrd WA: Anticoagulants and cataract surgery. Ophthalmic Surg 19:2212221988

  • 17

    Kallio HPaloheimo MMaunuksela EL: Haemorrhage and risk factors associated with retrobulbar/peribulbar block: a prospective study in 1383 patients. Br J Anaesth 85:7087112000

  • 18

    Katholi RENolan SPMcGuire LB: Living with prosthetic heart valves. Subsequent noncardiac operations and the risk of thromboembolism or hemorrhage. Am Heart J 92:1621671976

  • 19

    Katz JFeldman MABass EBLubomski LHTielsch JMPetty BG: Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology 110:178417882003

  • 20

    Kim DJSuh SHKim BMKim DIHuh SKLee JW: Hemorrhagic complications related to the stent-remodeled coil embolization of intracranial aneurysms. Neurosurgery 67:73792010

  • 21

    Lip GYHDurrani OMRoldan VLip PLMarin FReuser TQ: Peri-operative management of ophthalmic patients taking antithrombotic therapy. Int J Clin Pract 65:3613712011

  • 22

    McCormack PSimcock PRTullo AB: Management of the anticoagulated patient for ophthalmic surgery. Eye (Lond) 7:7497501993

  • 23

    McMahan LB: Anticoagulants and cataract surgery. J Cataract Refract Surg 14:5695711988

  • 24

    Morris AElder MJ: Warfarin therapy and cataract surgery. Clin Experiment Ophthalmol 28:4194222000

  • 25

    Narendran NWilliamson TH: The effects of aspirin and warfarin therapy on haemorrhage in vitreoretinal surgery. Acta Ophthalmol Scand 81:38402003

  • 26

    Niemi TArmstrong E: Thromboprophylactic management in the neurosurgical patient with high risk for both thrombosis and intracranial bleeding. Curr Opin Anaesthesiol 23:5585632010

  • 27

    Niemi TSilvasti-Lundell MArmstrong EHernesniemi J: The Janus face of thromboprophylaxis in patients with high risk for both thrombosis and bleeding during intracranial surgery: report of five exemplary cases. Acta Neurochir (Wien) 151:128912942009

  • 28

    Ortel TL: Perioperative management of patients on chronic antithrombotic therapy. Hematology (Am Soc Hematol Educ Program) 2012:5295352012

  • 29

    Otley CCFewkes JLFrank WOlbricht SM: Complications of cutaneous surgery in patients who are taking warfarin, aspirin, or nonsteroidal anti-inflammatory drugs. Arch Dermatol 132:1611661996

  • 30

    Palareti GLegnani C: Warfarin withdrawal. Pharmacokinetic-pharmacodynamic considerations. Clin Pharmacokinet 30:3003131996

  • 31

    Panczykowski DMOkonkwo DO: Premorbid oral antithrombotic therapy and risk for reaccumulation, reoperation, and mortality in acute subdural hematomas. J Neurosurg 114:47522011

  • 32

    Roberts CWWoods SMTurner LS: Cataract surgery in anticoagulated patients. J Cataract Refract Surg 17:3093121991

  • 33

    Robinson GANylander A: Warfarin and cataract extraction. Br J Ophthalmol 73:7027031989

  • 34

    Rotenstreich YRubowitz ASegev FJaeger-Roshu SAssia EI: Effect of warfarin therapy on bleeding during cataract surgery. J Cataract Refract Surg 27:134413462001

  • 35

    Saitoh AKSaitoh ATaniguchi HAmemiya T: Anticoagulation therapy and ocular surgery. Ophthalmic Surg Lasers 29:9099151998

  • 36

    Schanbacher CFBennett RG: Postoperative stroke after stopping warfarin for cutaneous surgery. Dermatol Surg 26:7857892000

  • 37

    Shalom AWong L: Outcome of aspirin use during excision of cutaneous lesions. Ann Plast Surg 50:2962982003

  • 38

    Shuler JDPaschal JFHolland GN: Antiplatelet therapy and cataract surgery. J Cataract Refract Surg 18:5675711992

  • 39

    Souto JCOliver AZuazu-Jausoro IVives AFontcuberta J: Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: a prospective randomized study. J Oral Maxillofac Surg 54:27321996

  • 40

    Suyama KHayashi KNagata I: [Cervicocephalic arterial dissection.]. Brain Nerve 60:111511232008. (Jpn)

  • 41

    Sweeney JMVasan Rvan Loveren HRYoussef ASAgazzi S: Catheter fixation and ligation: a simple technique for ventriculostomy management following endovascular stenting. J Neurosurg 118:100910132013

  • 42

    Wong JMZiewacz JEPanchmatia JRBader AMPandey ASThompson BG: Patterns in neurosurgical adverse events: endovascular neurosurgery. Neurosurg Focus 33:5E142012

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Article Information

Correspondence Yoshikazu Ogawa, Department of Neurosurgery, Kohnan Hospital, 4-20-1 Nagamachiminami, Taihaku-ku, Sendai, Miyagi 982-8523, Japan. email: yogawa@kohnan-sendai.or.jp.

INCLUDE WHEN CITING Published online February 20, 2015; DOI: 10.3171/2014.9.JNS141088.

DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Ah-Weng ANatarajan SVelangi SLangtry JA: Preoperative monitoring of warfarin in cutaneous surgery. Br J Dermatol 149:3863892003

2

Alam MGoldberg LH: Serious adverse vascular events associated with perioperative interruption of antiplatelet and anticoagulant therapy. Dermatol Surg 28:9929982002

3

Alcalay J: Cutaneous surgery in patients receiving warfarin therapy. Dermatol Surg 27:7567582001

4

Armstrong MJGronseth GAnderson DCBiller JCucchiara BDafer R: Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 80:206520692013

5

Baron THKamath PSMcBane RD: Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 368:211321242013

6

Billingsley EMMaloney ME: Intraoperative and postoperative bleeding problem in patients taking warfarin, aspirin, and nonsteroidal anti-inflammatory agents. A prospective study. Dermatol Surg 23:3813831997

7

Cannon PDDharmar VT: Minor oral surgical procedures in patients on oral anticoagulants—a controlled study. Aust Dent J 48:1151182003

8

Carrel TPKlingenmann WMohacsi PJBerdat PAlthaus U: Perioperative bleeding and thromboembolic risk during non-cardiac surgery in patients with mechanical prosthetic heart valves: an institutional review. J Heart Valve Dis 8:3923981999

9

Carter KMiller KM: Phacoemulsification and lens implantation in patients treated with aspirin or warfarin. J Cataract Refract Surg 24:136113641998

10

Custer PLTrinkaus KM: Hemorrhagic complications of oculoplastic surgery. Ophthal Plast Reconstr Surg 18:4094152002

11

Devani PLavery KMHowell CJ: Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary?. Br J Oral Maxillofac Surg 36:1071111998

12

Devereaux PJMrkobrada MSessler DILeslie KAlonso-Coello PKurz A: Aspirin in patients undergoing non-cardiac surgery. N Engl J Med 370:149415032014

13

Dunn ASTurpie AG: Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med 163:9019082003

14

Evans ILSayers MSGibbons AJPrice GSnooks HSugar AW: Can warfarin be continued during dental extraction? Results of a randomized controlled trial. Br J Oral Maxillofac Surg 40:2482522002

15

Gainey SPRobertson DMFay WIlstrup D: Ocular surgery on patients receiving long-term warfarin therapy. Am J Ophthalmol 108:1421461989

16

Hall DLSteen WH JrDrummond JWByrd WA: Anticoagulants and cataract surgery. Ophthalmic Surg 19:2212221988

17

Kallio HPaloheimo MMaunuksela EL: Haemorrhage and risk factors associated with retrobulbar/peribulbar block: a prospective study in 1383 patients. Br J Anaesth 85:7087112000

18

Katholi RENolan SPMcGuire LB: Living with prosthetic heart valves. Subsequent noncardiac operations and the risk of thromboembolism or hemorrhage. Am Heart J 92:1621671976

19

Katz JFeldman MABass EBLubomski LHTielsch JMPetty BG: Risks and benefits of anticoagulant and antiplatelet medication use before cataract surgery. Ophthalmology 110:178417882003

20

Kim DJSuh SHKim BMKim DIHuh SKLee JW: Hemorrhagic complications related to the stent-remodeled coil embolization of intracranial aneurysms. Neurosurgery 67:73792010

21

Lip GYHDurrani OMRoldan VLip PLMarin FReuser TQ: Peri-operative management of ophthalmic patients taking antithrombotic therapy. Int J Clin Pract 65:3613712011

22

McCormack PSimcock PRTullo AB: Management of the anticoagulated patient for ophthalmic surgery. Eye (Lond) 7:7497501993

23

McMahan LB: Anticoagulants and cataract surgery. J Cataract Refract Surg 14:5695711988

24

Morris AElder MJ: Warfarin therapy and cataract surgery. Clin Experiment Ophthalmol 28:4194222000

25

Narendran NWilliamson TH: The effects of aspirin and warfarin therapy on haemorrhage in vitreoretinal surgery. Acta Ophthalmol Scand 81:38402003

26

Niemi TArmstrong E: Thromboprophylactic management in the neurosurgical patient with high risk for both thrombosis and intracranial bleeding. Curr Opin Anaesthesiol 23:5585632010

27

Niemi TSilvasti-Lundell MArmstrong EHernesniemi J: The Janus face of thromboprophylaxis in patients with high risk for both thrombosis and bleeding during intracranial surgery: report of five exemplary cases. Acta Neurochir (Wien) 151:128912942009

28

Ortel TL: Perioperative management of patients on chronic antithrombotic therapy. Hematology (Am Soc Hematol Educ Program) 2012:5295352012

29

Otley CCFewkes JLFrank WOlbricht SM: Complications of cutaneous surgery in patients who are taking warfarin, aspirin, or nonsteroidal anti-inflammatory drugs. Arch Dermatol 132:1611661996

30

Palareti GLegnani C: Warfarin withdrawal. Pharmacokinetic-pharmacodynamic considerations. Clin Pharmacokinet 30:3003131996

31

Panczykowski DMOkonkwo DO: Premorbid oral antithrombotic therapy and risk for reaccumulation, reoperation, and mortality in acute subdural hematomas. J Neurosurg 114:47522011

32

Roberts CWWoods SMTurner LS: Cataract surgery in anticoagulated patients. J Cataract Refract Surg 17:3093121991

33

Robinson GANylander A: Warfarin and cataract extraction. Br J Ophthalmol 73:7027031989

34

Rotenstreich YRubowitz ASegev FJaeger-Roshu SAssia EI: Effect of warfarin therapy on bleeding during cataract surgery. J Cataract Refract Surg 27:134413462001

35

Saitoh AKSaitoh ATaniguchi HAmemiya T: Anticoagulation therapy and ocular surgery. Ophthalmic Surg Lasers 29:9099151998

36

Schanbacher CFBennett RG: Postoperative stroke after stopping warfarin for cutaneous surgery. Dermatol Surg 26:7857892000

37

Shalom AWong L: Outcome of aspirin use during excision of cutaneous lesions. Ann Plast Surg 50:2962982003

38

Shuler JDPaschal JFHolland GN: Antiplatelet therapy and cataract surgery. J Cataract Refract Surg 18:5675711992

39

Souto JCOliver AZuazu-Jausoro IVives AFontcuberta J: Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: a prospective randomized study. J Oral Maxillofac Surg 54:27321996

40

Suyama KHayashi KNagata I: [Cervicocephalic arterial dissection.]. Brain Nerve 60:111511232008. (Jpn)

41

Sweeney JMVasan Rvan Loveren HRYoussef ASAgazzi S: Catheter fixation and ligation: a simple technique for ventriculostomy management following endovascular stenting. J Neurosurg 118:100910132013

42

Wong JMZiewacz JEPanchmatia JRBader AMPandey ASThompson BG: Patterns in neurosurgical adverse events: endovascular neurosurgery. Neurosurg Focus 33:5E142012

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