Postoperative Pharmacologic Anticoagulation following Temporal Lobe Resection of a Gliosarcoma in a Hypercoagulable Patient

Brian Gable ,Gabrielle Hassinger,Bs Heslin ,Bs Kellish ,Bo Yu

doi:10.31986/issn.2578-3343_vol2iss1.9

Abstract

Gliosarcomas are a rare subtype of glioblastomas associated with high rates of malignancy-associated venous thromboembolism (VTE). VTE risk is further increased in hypercoagulable patients upon discontinuing pharmacologic anticoagulation for surgery. We present a 60-year old obese male with history of hypercoagulability on apixaban who developed extensive thrombosis following resection of a gliosarcoma. Prior to temporal lobe resection, apixaban was discontinued and an IVC filter placed. On postoperative day 4, imaging revealed thrombosis above the IVC filter extending to the bilateral common, internal and external iliac, and femoral veins, requiring immediate anticoagulation and suction thrombectomy. Clinicians must balance the risk of VTE and intracerebral hemorrhage following neurosurgical. While withholding pharmacologic VTE is standard, hypercoagulable patients may benefit from pharmacologic prophylaxis postoperatively. Patients with multiple risk factors including malignancies with high rates VTE, like gliosarcomas, medical and hematological conditions, including idiopathic erythrocytosis, and history of VTE may benefit from earlier pharmacologic prophylaxis.

Highlights

Glioblastomas are the most common primary malignant brain tumors in adults with a median age of diagnosis around 55-60 years old
Gliosarcomas are a rare subtype of glioblastomas associated with high rates of malignancy-associated venous thromboembolism (VTE)
We present a 60-year old obese male with history of hypercoagulability on apixaban who developed extensive thrombosis following resection of a gliosarcoma

Summary

INTRODUCTION

Glioblastomas are the most common primary malignant brain tumors in adults with a median age of diagnosis around 55-60 years old. The mesenchymal component represented spindle cell sarcoma that was reticulin rich on histochemical staining, which was consistent with WHO Grade IV gliosarcoma Prior to his operation, apixaban was held and a retrievable inferior vena cava (IVC) filter was placed for VTE prophylaxis. The patient was not restarted on pharmaceutical anticoagulation due to the potential risk of ICH causing a catastrophic bleed He received a unit of platelets on postoperative day three due to thrombocytopenia following neurosurgery with a citrate tube platelet count of 77x103/uL, decreased from 263x103/uL on admission. LMWH was chosen in place of a direct oral anticoagulation due to the risk of future neurosurgical intervention and availability of a reversal agent He is continuing his care with neurosurgery and radiation oncology, feeling well and has not developed any further VTE since discharge

Findings

DISCUSSION

CONCLUSION