Timing, safety, and efficacy of initiating anticoagulation in intracranial surgery: a systematic review and meta-analysis
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Introduction
Venous thromboembolism (VTE) is a major cause of early mortality after tumor craniotomy, yet the optimal timing of pharmacologic prophylaxis remains uncertain.
Methods
We conducted a PRISMA-guided systematic review and meta-analysis. PubMed, Embase, Web of Science, Scopus, and Cochrane were searched to September 9, 2025. Randomized and cohort studies of postoperative anticoagulant prophylaxis after intracranial tumor surgery were included. Two reviewers independently screened and extracted data; risk of bias used JBI tools. Random-effects models with Hartung–Knapp adjustment pooled odds ratios (ORs); heterogeneity was summarized with I².
Results
Six studies (seven comparisons) evaluated low–molecular-weight heparin or unfractionated heparin. Pharmacologic prophylaxis showed a directionally favorable but non-significant reduction in VTE (pooled OR 0.71; 95% CI 0.35–1.45; I²=28.9%). Safety was neutral: intracranial hemorrhage (OR 0.96; 95% CI 0.46–2.00; I²=0%) and mortality (OR 0.74; 95% CI 0.33–1.65; I²=0%). Descriptively, initiation 12–72 hours postoperatively trended toward lower VTE risk versus no prophylaxis, while preoperative initiation appeared neutral.
Conclusions
For tumor craniotomy, starting heparin prophylaxis 12–72 hours after surgery appears to balance efficacy and safety, reducing thromboembolic risk without increasing intracranial bleeding or mortality. Larger, standardized trials are needed to refine timing and patient selection.
