The Neurosurgeon's Dilemma—Do Antiplatelet/Anticoagulant Medications Increase the Risk of Catheter-Associated Hemorrhage in External Ventricular Drain Placement?

Abstract

IntroductionExternal ventricular drain (EVD) placement is a common neurosurgical procedure that can be performed at bedside. A frequent complication following EVD placement is catheter-associated hemorrhage (CAH). The hemorrhage itself is rarely clinically significant but may be complicated in patients taking anticoagulant or antiplatelet (AC/AP) medications. MethodsA total of 757 patients were who underwent EVD placement at bedside were included as part of a retrospective study at a large academic medical center. Demographic factors, use of AC/AP therapies, and several other clinical variables were recorded and assessed in univariate and multivariate regression analysis for association with CAH and mortality. ResultsOne hundred (13.2%) patients experienced CAH within 24 hours of the procedure. After univariate analysis, in two tandem-run multivariate regression analyses after stepwise variable selection, use of two or more AC/AP agents (OR=2.362, p=0.020) and dual antiplatelet therapy with aspirin and clopidogrel (OR=3.72, p=0.009) were significantly associated with CAH. Use of non-coated catheters was a protective factor against CAH compared to use of antibiotic-coated catheters (OR=0.55, p=0.019). Multivariate analysis showed age, multi-agent therapy, and thrombocytopenia were significantly associated with increased mortality. ConclusionThere was increased risk of CAH after EVD placement in patients taking more than one AC/AP agent regardless of presenting pathology. In particular, use of aspirin and clopidogrel combined was associated with significantly higher odds of CAH, although it was not associated with higher mortality. In addition, there appears to be an association between use of antibiotic-coated catheters and CAH across univariate and multivariate analysis.