Original Article
Clinically Diagnosed Postoperative Venous Thromboembolism in a Neurosurgery
Practice in Nigeria
Amos O. Adeleye1 and Gabriel O. Ogun2
- INTRODUCTION: Postoperative venous thromboembo-
lism (VTE) is a major surgical complication, fraught with
high case fatality rate, to which neurosurgical patients are
particularly prone. There is dearth of data on this problem
in the neurosurgical literature from sub-Saharan Africa.
- MATERIALS AND METHODS: A 6-year prospective
descriptive study of postoperative VTE in a neurosurgeons
clinical practice in Nigeria is hereby presented. The clin-
ical case of a fatal, postmortem-confirmed post craniotomy
VTE also is annotated.
- RESULTS: There were 10 cases of clinically diagnosed
neurosurgical postoperative VTE, representing 2.4% of the
surgical patients population. The cases were diagnosed
from clinical impressions supplemented with laboratory
investigations like the Doppler ultrasonography with
B-mode imaging of the deep veins of the lower extremities,
and chest computed tomographic angiography. Six of these
10 cases died, a case fatality rate of 60%. Meningiomas were
the intracranial tumours operated on in 60% of the cases.
- CONCLUSIONS: Postoperative venous thromboembolism
has a very high case fatality rate among these neurosur-
gical patients. There is need for continuing surveillance of
this problem, as well as a heightened vigilance to prevent
and treat it in our neurosurgical patient populations.
Key words
- Deep-vein thrombosis
- Developing country
- Neurosurgery
- Postoperative
- Pulmonary embolism
- Venous thromboembolism
Abbreviations and Acronyms
CT: Computed tomography
CTA: Computed tomographic angiography
Doppler USS: Doppler ultrasound scan with B-mode imaging
DVT: Deep-vein thrombosis
ICU: Intensive care unit
IPC: Intermittent pneumatic compression
LMWH: Low-molecular-weight heparins
PE: Pulmonary embolism
WORLD NEUROSURGERY 89: 259-265, MAY 2016
INTRODUCTION
V
enous thromboembolism (VTE), including lower extremity
deep-vein thrombosis (DVT) and pulmonary embolism
(PE), is a devastating postoperative complication with high
rate of case fatality. Postoperatively, neurosurgical patients among
all other in-hospital surgical cohorts are particularly prone to the
complication, partly as the result of perioperative (pre- and post-
operative) immobility that many neurologic illnesses predispose
patients to, the long hours of surgery involved in many neuro-
surgical operative procedures, and the intrinsic biology of some
neurosurgical lesions, including brain tumors like meningiomas,
that appears to promote thrombogenesis.1-3
It has therefore been opined that the neurosurgeon has 3
practical problems regarding the issue of VTE: preventing DVT,
diagnosing it, and treating it.3 Hence, several scientic studies
and reviews from the developed countries show increasing
efforts by neurosurgery units to address postoperative VTE along
these 3-pronged directions, either singly or in combination.3-8 In
contrast, it appears that only scant attention, if any, is paid to this
problem in the less-developed parts of the world. We are aware of
only 1 report on the subject of postoperative VTE in contemporary
literature from our region,9 but even this was only a questionnaire-
based survey of practice of thromboprophylaxis among select
surgeons. The report showed low awareness of the use of
thromboprophylaxis among the study subjects.9 Thus, there
appears to be no existing easily accessible literature in sub-
Sahara Africa on the burden of postoperative VTE.
Sometime in the year 2009, a fatal, postmortem-conrmed VTE
marked the unheralded catastrophic end to an otherwise-successful
POD: Postoperative day
TED: Thromboembolic-deterrent stockings
VTE: Venous thromboembolism
From the 1Division of Neurological Surgery, Department of Surgery, and 2Department of
Pathology, College of Medicine, University of Ibadan, and University College Hospital, UCH,
Ibadan, Nigeria
To whom correspondence should be addressed: Amos O. Adeleye, M.B.B.S.
[E-mail: femdoy@yahoo.com]
Citation: World Neurosurg. (2016) 89:259-265.
http://dx.doi.org/10.1016/j.wneu.2016.01.069
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2016 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org 259

AMOS O. ADELEYE AND GABRIEL O. OGUN
surgical resection of a cavernous sinus meningioma in our skull
base surgery unit of a difcult practice setting in this region. One
principle response this event elicited in our practice was a height-
ened vigilance to prevent this complication among our patient
population and a prospective surveillance for its incidence. In this
report a descriptive analysis of cases of VTE among a neurosurgical
operative surgical cohort in this sub-Saharan African developing
country is presented. The fatal index case also is illustrated.
MATERIALS AND METHODS
This is a 6-year prospective observational study that used the
prospective, consecutive database of the clinical records of all the
patients who underwent neurosurgical operations, spinal or cra-
nial, in the principal authors practice since the year 2009. The
clinical records of all neurosurgical operative cases in which there
was clinical evidence in keeping with VTE, with or without labo-
ratory conrmation, were captured in clinical summary forms.
In this report, the clinical summary of 1 fatal case whose clinical
suspicion was conrmed on necropsy is presented in addition to a
descriptive analysis of all the other cases seen between the year
2009 and 2015 in our operative surgical experience. Data analyzed
include each patients age, sex, and clinical diagnosis; presumed
clinical predisposition to VTE, including duration of surgery, and
presence of perioperative reduced mobility; the time duration
from surgery to clinical suspicion of the VTE, as well as the means
of conrming the diagnosis; the treatment offered, outcome of
treatment (death or survival), and the follow-up duration for the
survivors.
RESULTS
Case Illustration
A 43-year-old woman presented with a 3-year history of progres-
sive blurring of vision that became total 6 months before our
review. There was associated history of recurrent headache,
galactorrhea of 3 years duration, and amenorrhea of 1-year
duration. Clinical examination revealed a young woman with
normal mental status. She was blind bilaterally, visual acuity being
nil light perception on the right side and hand movement on the
left. Both pupils were 4 mm in diameter, nonreacting, and showed
relative afferent pupillary defect. Fundoscopy revealed bilateral
optic atrophy. There was subtle bilateral abducens nerve palsy and
galactorrhea. Her vital signs were normal.
Cranial computed tomography (CT) scanning showed a huge
sellar/parasellar mass, brilliantly contrast enhanced with calcic
deposits (Figure 1A). Cranial magnetic resonance imaging showed
a bilobed frontobasal contrast-enhanced isointense mass involving
the tuberculum-planum area with involvement of the sellar/
suprasellar cisterns and cavernous sinus bilaterally. The posterior
extension encircled the basilar artery by approximately 50%. The
diagnosis of a cavernous sinus meningioma was made.
Gross total tumor excision of the cavernous sinus tumor was
achieved via a right fronto-orbito-zygomatic craniotomy with a
right anterior extradural cliniodectomy. Intraoperative ndings
were that of a huge suprasellar mass with extension into the
cavernous sinus; it was grayish white, well-encapsulated, brous,
and moderately vascular. The optic nerves were plastered to the
260 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.01.069
ORIGINAL ARTICLE
NEUROSURGICAL POSTOPERATIVE VENOUS THROMBOEMBOLISM
tumor and stretched into mere ribbons. Both carotid arteries were
exposed. Operative time was 6 hours. Cranial CT scanning 24
hours postoperatively showed evidence of total tumor excision
with no signicant tumor bed hemorrhage (Figure 1B). The
histology was reported as transitional meningioma, World
Health Organization Grade I.
The immediate postoperative period was uneventful. The
patient was ambulated on the morning after the operation and
discharged from the intensive care unit (ICU) the second post-
operative day (POD). The Glasgow Coma Scale score remained 15;
both pupils were 4 mm each and nonreacting. Her clinical con-
dition had remained stable, with only occasional periods of subtle
confusion, and she continued to ambulate with only minimal
support as a result of her blindness. She was being prepared for
discharge from the hospital on POD 11. On the evening of the POD
12, she complained of being weak although was otherwise clini-
cally stable. Attention was, however, drawn to her in the early
hours of POD 13 when she was observed to be gasping. She went
into cardiopulmonary arrest from which she could not be
resuscitated.
The clinical suspicion was that of a fatal VTE. A postmortem
examination was requested, which revealed no clinically signi-
cant intracranial ndings but a bilateral saddle embolism in the
pulmonary arterial vasculature (Figure 2).
Clinical Series
Nine other clinically diagnosed cases of VTE were recorded,
making 10 in all, of a total of 422 (2.4%) patients who underwent
major operative neurosurgery care, cranial and spinal, in the
principal neurosurgeons practice in the study period. Further
clinical details of these neurosurgical postoperative cases of VTE
are shown in Table 1. Seven were female, and 3 were male. The
median age was 50 years (range, 41 70).
Intracranial meningioma occurred in 6 cases; giant pituitary
adenoma (5 cm), brain metastasis (colorectal primary disease
with previous hospital presentation with DVT), traumatic brain
injury, and cervical syringomyelia10 occurred in 1 case each. The
duration of surgery ranged between 1.67 and 6.00 hours, with
median of 3.38; 7 of the cases lasted 4 hours. Apart from the
moderately long hours of the surgery, 3.50 hours, case 5 (Table 1)
did not have any other apparent clinical predisposition to the
postoperative development of VTE: there was no perioperative
reduced mobility, and the patient was mobilized out of bed on
the rst POD. The rest of the cases had prolonged reduced
mobility in the perioperative (especially preoperative) period.
Case number 3 presented primarily in the hospital with clinical
and Doppler ultrasound scan with B-mode imaging (Doppler
USS)-diagnosed DVT complicating an anorectal carcinoma. There
was associated neurologic decit from associated brain metas-
tasis. The DVT was managed successfully with chemical anti-
coagulation; serial Doppler USS showed clots lysis. She underwent
an awake craniotomy lasting only 3 hours to resect the brain
deposit, did well, and then had abdominal surgical exploration to
address the primary lesion. VTE recurred, and she died on POD 5
after the laparotomy, or POD 36 after the craniotomy.
On 2 specic occasions, cases 2 and 6, the clinical diagnosis of
the VTE was conrmed, antemortem, with bilateral lower-limb
Doppler USS with B-mode imaging and chest computed
 ORIGINAL ARTICLE
AMOS O. ADELEYE AND GABRIEL O. OGUN NEUROSURGICAL POSTOPERATIVE VENOUS THROMBOEMBOLISM

Figure 1. (A) Cranial computed tomography (CT) scan in axial cuts showing the cavernous sinus meningioma and its
high suprasellar extension. (B) CT scan on postoperative day 1 revealed gross total tumor excision and only minimal
tumor bed operative changes.

tomographic angiography (CTA). The 2 cases were treated suc-
cessfully with chemical anticoagulation and multispecialty man-
agement in the ICU. Only case 1, the one presented, had
postmortem examination. Most of the other cases with clinical
suspicion of VTE in this study, DVT with or without PE, had
Doppler USS of the lower limbs as the only more denitive labo-
ratory investigation. Other nonspecic investigations (chest x-ray,
electrocardiography, and serum D-dimer levels) were performed in
some of the cases, as shown in the table. This is largely due to
logistic constraints: either lack of facilities at the moment of need
or lack of funds by the care givers to procure the investigations.
Six of the patients died, for a mortality rate of 60% in this group
of patients. Two of the deaths (cases 1 and 3, Table 1) occurred
suddenly before any anticoagulation could be commenced. The
other 4 received chemical anticoagulation with low-molecular-
weight heparins (LMWHs) and warfarin in doses titrated to the

WORLD NEUROSURGERY 89: 259-265, MAY 2016 www.WORLDNEUROSURGERY.org 261


AMOS O. ADELEYE AND GABRIEL O. OGUN
Figure 2. Findings on postmortem examination after the death of the patient on postoperative day 13 on clinical
suspicion of a fatal pulmonary embolism. (A) The saddle emboli in the 2 pulmonary arteries are shown. (B) Apart from
the soft-tissue changes of the left anterolateral craniotomy site, there were no other significant intracranial findings.
therapeutic ratio (international normalized ratio of 2 2.5). As far as
we could tell from clinical impressions, there was no case of
apparent neurologic complication of this anticoagulation regime in
any of the cases before their death.
The cause of death was believed to be the VTE in all the
patients. This fact was conrmed at autopsy in the case illustra-
tion. In the rest, the clinical course of each case after the devel-
opment of the symptomatology of VTE was the basis for the nal
diagnosis of the cause of death: progressive, worsening limb
swelling; hemodynamic instability; and desaturation on supple-
mental oxygen therapy in the ICU. The survivors have been fol-
lowed up for a range of 16 47 months. These survivors included
the 2 cases who had the full-blown clinical features of DVT and PE,
had the full complements of the conrmatory laboratory
investigations, including chest CTA that were available in our
practice, and were monitored and treated in the ICU by a multi-
specialty team that included the neurosurgeons, hematologists,
pulmonologists, intensive unit anesthetists, and physiotherapists,
among others.
DISCUSSION
This study describes the clinical proles of patients with clinically
diagnosed postoperative VTE among a neurosurgical patient
population from a developing country. It appears to be the rst
document of this nature on the subject from our region. There was
a VTE rate of 2.4% and case fatality rate of 60%. Intracranial
meningiomas were the lesions operated on in 60% of the cases,
and 70% occurred among the female sex.
When in the year 2009, we had the rare chance of conrming
with postmortem anatomic study, a clinically suspected case of
fatal postoperative VTE we took some steps to address the issue.
First, we paid more particular attention to our patients periop-
erative mobility, as much as is practicable. Although some
patients presented with paralysis and physical immobility from
their neurologic illness, others simply just slipped into a state of
inactivity from mental exhaustion concerning their illness. We
usually nudged these ones out of bed to take walks around the
262 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.01.069
ORIGINAL ARTICLE
NEUROSURGICAL POSTOPERATIVE VENOUS THROMBOEMBOLISM
ward in the days preceding their surgical operations. A strict
regime of full, out-of-bed walking mobilization also was enforced
as a rule, from the morning of the rst day postoperatively, for
those who are able, even on the ICU oor. We usually also apply
graduated compressive stockings to those cases that are not as
easily mobilized as desired. Further, aggressive chest and limb
physiotherapy, including frequent, sustained active and passive
limb movements, is encouraged. These same measures were
employed in those patients who still succumbed to postoperative
VTE detailed in this report. There is the fact, though, that some of
them (say, in a coma or quadriparesis in the immediate post-
operative period) could not be mobilized soon enough post-
operatively, they received thromboembolic-deterrent stockings
(TED) and had chest and limb physical therapy in bed.
Prophylaxis for VTE
Early postsurgical mobilization of patients is known to be bene-
cial in preventing VTE,11,12 as well as mechanical thrombopro-
phylactic interventions like intermittent pneumatic compression
(IPC) and graduated compression of the lower extremities using
TED.3,8,13 In addition, these mechanical measures are sometimes
also supplemented with chemical thromboprophylaxis with
unfractionated heparin or the LMWHs in patients who are at still
more substantial risks of VTE.3,8,13
The use of chemoprophylaxis in neurosurgery patient peri-
operatively is, however, still a much-debated issue.7 Although
LMWH and or low-dose unfractionated heparin for thrombopro-
phylaxis have proven,6,13 even superior, efcacy for VTE either
alone or as supplements to mechanical means, the heparins tend
to cause more intracranial hemorrhage as a complication of their
use in operative neurosurgical patients.7,14-17 This calls for the
need for the postoperative monitoring of the patients clinical
progress to be more CT-intensive for the purpose of trouble-
shooting any change in the clinical-neurologic status for possible
intracranial bleed. This is, however, an unaffordable luxury in
our practice. An even more practical concern, however, to the
use of the heparins in our clinical-surgical practice is the fact that
the logistic requirements for monitoring and treating the
WORLD NEUROSURGERY 89: 259-265, MAY 2016
Table 1. The Clinical Profiles of Cases of Postoperative VTE in a Neurosurgery Practice from Nigeria
Sex/Age,
S/N years
1 F/43
2 M/41
3 F/63
4 F/53
5 F/43
6 M/62
7 F/41
8 F/47
www.WORLDNEUROSURGERY.org
9 F/70
10 M/70
VTE, venous thromboembolism; S/N, serial number; DVT, deep-vein thrombosis; PE, pulmonary embolism; POD, postoperative day; Doppler USS, Doppler ultrasound scan with B-mode imaging; CXR, chest x-ray; ECG, electrocardiogram; CT,
computed tomography.
263
AMOS O. ADELEYE AND GABRIEL O. OGUN
Clinical Diagnosis/Predisposition DVT/PE Diagnosis Treatment Outcome/Follow-up
Tuberculum sellar/cavernous sinus meningioma, Clinical, POD 13; postmortem Sudden event, died before Death
duration of surgery 6 hours (ambulated POD 1); treatment begun
blindness, reduced mobility preoperatively
for 1 year
Cervical syringomyelia, duration of surgery 5 Clinical, POD 48; Lower-limbs Doppler Chemical anticoagulation; Improved, discharged
hours; prolonged preoperative quadriparesis USS, CXR, ECG, Echo, Chest CT intensive unit care home/32 months
angiography e DVT/PE
Brain metastasis; duration of surgery 3 hours; Clinical e 5 days postexploratory Died before recommencement of Death
primary anorectal carcinoma with left iliofemoral laparotomy/colostomy (36 days anticoagulation
DVT on admission postcraniotomy, brain metastasectomy)
e DVT/PE
Convexity meningioma; duration of surgery 2.75 Clinical, POD 14; CXR, ECG e DVT/PE Chemical anticoagulation; Death
hours (ambulated 4 hours postoperatively awake intensive unit care
craniotomy); preoperative hemiparesis, reduced
mobility
Spheno-orbital meningioma; duration of surgery Clinical, POD 10; CXR, ECG, D-dimer, Chemical anticoagulation Improved, discharged
3.5 hours (ambulated POD 1); nil obvious Lower-limbs Doppler USS e DVT/PE home/7 months
predisposition
NEUROSURGICAL POSTOPERATIVE VENOUS THROMBOEMBOLISM
Falcine meningioma; duration of surgery 4 hours Clinical, POD 7; CXR, ECG, Echo, lower- Chemical anticoagulation; Improved, discharged
(ambulated, unsuccessfully POD 1); prolonged limbs Doppler USS, Chest CT intensive unit care home/15 months
preoperative immobilization/inanition angiography e DVT/PE
Right parietal convexital meningioma; duration of Clinical, POD 9; lower-limb Doppler USS, Chemical anticoagulation Improved, discharged
surgery 3 hours (ambulated 4 hours D-dimer e Right leg DVT home/2 months
postoperatively awake craniotomy); preoperative
reduced mobility-seizures
Giant olfactory groove meningioma; duration of Clinical, POD 30; associated Died before full evaluation Death
surgery 6 hours (ambulated POD 1); preoperative postoperative sepsis
blindness, reduced mobility for 6months
Intracranial bleed (acute subdural and Clinical, POD 3; lower-limb Doppler USS Chemical anticoagulation; Death
intracerebral) from traumatic brain injury; intensive unit care
duration of surgery 1.67 hours; pre- and
postoperative reduced mobility
Giant pituitary adenoma; duration of surgery 3.25 Clinical, POD 9; lower-limb Doppler USS Chemical anticoagulation; Death
hours (ambulated POD 2); perioperative reduced intensive unit care
mobility, postoperative hyperglycemia
ORIGINAL ARTICLE
 ORIGINAL ARTICLE
AMOS O. ADELEYE AND GABRIEL O. OGUN NEUROSURGICAL POSTOPERATIVE VENOUS THROMBOEMBOLISM

complications of their use for thromboprophylaxis are still not
feasible in our low-resource health system.8,16
Second, we maintained a heightened vigilance and surveillance
for the occurrence of post-neurosurgical VTE in our practice.
Patients were monitored for any slight clinical suspicion of DVT
and or PE. Those with strong suspicions received low-dose LMWH
and Doppler ultrasonographic evaluation of the lower limbs for
DVT. The ones with rmer clinical diagnosis are moved to the
ICU, and then referred for evaluations and joint management by
the pulmonologists, hematologists, and physiotherapists. They
are also further evaluated with chest CTA for the presence of PE, as
logistics permit. These are the cases presented in this study.
It is not certain to what extent these measures adopted by us
helped to curtail this signicant perioperative complication, but
our VTE rate of 2.4% compares well with the literature.4,5,18 The
fact remains, however, that all patients who have been proled
here are only the clinically obvious cases. This surely is 1 limitation
of this study, because it is known that postneurosurgical operative
prevalence of VTE can be as high as 50% with only a fraction of it,
17%, coming to clinical attention.2,4,15 Patients undergoing
neurosurgical and major orthopedic operations are well-known
high-risk groups for VTE for whom thromboprophylaxis is high-
ly recommended.2,8 The rst-line measures include early and
frequent ambulation postoperatively in those who are able to, and
mechanical measures including IPC and TED in those less
ambulatory.3,8 Reports concerning the effectiveness of graduated
compression of the lower extremity using the TED are, however,
varied. Yet this is the only measure for mechanical thrombopro-
phylaxis that is available and easily affordable in our practice.
Although some studies report lower efcacy than IPC,8 others
suggest outcomes to the contrary.19,20 Whatever the reported
level of effectiveness, one main known demerit of TED is with
their t to the end users.4,5,8 This is indeed a practical problem
with their use in our real-world practice. Perhaps because most of
the brands that are available over the counter were manufactured
for foreign populations with different physiognomies, many TED
that are in use among our patient populations are not infrequently
too loose to be really effectual.
Limitations
It might have been better to develop an algorithm for preventing/
treating VTE among our patients according to their risk strati-
cation. The high-risk group could then be screened/monitored not
just symptomatically as we do but could also undergo serial
Doppler USS. Again, this ideal is still something we have not yet
reached but are hopeful for in our practice. The small number of
the cases of VTE in this study, being only the ones clinically
diagnosed, also prevented a more robust statistical analysis of the
data with a view to determining the risk stratications of our
patient cohort for developing VTE. The only impressions so far are
that the female sex and those with meningiomas formed the
majority in this small series. All said, one apparent, main infer-
ence of this report is the fact that efforts at the prevention of
postoperative VTE in our neurosurgical practice are still rudi-
mentary and call for continuing striving for their improvements.
CONCLUSIONS
This study reports on the clinical proles of patients with clinically
diagnosed postoperative VTE among a neurosurgical patient
population from a developing country. It appears to be the rst
regional document on this subject. There was a VTE rate of 2.4%
and case fatality rate of 60%. The only thromboprophylactic
measures logistically available in this practice include periopera-
tive ambulation in those who are able and graduated compression
of the lower extremities using TED stockings and active/passive
limb exercises in those less mobile. There is the need for
improvement in the thromboprohylactic measures available for the
perioperative care of our high-risk neurosurgical patients. This
improvement for a start should ensure the availability of IPC for
our perioperative patients.

REFERENCES
1. Hull RD, Raskob GE, Hirsh J. Prophylaxis of
venous thromboembolism. An overview. Chest.
1986;89(5 suppl):374S-383S.
2. Swann KW, Black PM. Deep vein thrombosis and
pulmonary emboli in neurosurgical patients: a
review. J Neurosurg. 1984;61:1055-1062.
3. Hamilton MG, Hull RD, Pineo GF. Venous
thromboembolism in neurosurgery and neurology
patients: a review. Neurosurgery. 1994;34:280-296
[discussion: 96].
4. Auguste KI, Quinones-Hinojosa A, Berger MS.
Efcacy of mechanical prophylaxis for venous
thromboembolism in patients with brain tumors.
Neurosurg Focus. 2004;17:E3.
5. Auguste KI, Quinones-Hinojosa A, Gadkary C,
Zada G, Lamborn KR, Berger MS. Incidence of
venous thromboembolism in patients undergoing
craniotomy and motor mapping for glioma
without intraoperative mechanical prophylaxis to
the contralateral leg. J Neurosurg. 2003;99:680-684.
6. Chibbaro S, Tacconi L. Safety of deep venous
thrombosis prophylaxis with low-molecular-
weight heparin in brain surgery. Prospective
study on 746 patients. Surg Neurol. 2008;70:117-121
[discussion: 21].
7. Collen JF, Jackson JL, Shorr AF, Moores LK. Pre-
vention of venous thromboembolism in neuro-
surgery: a metaanalysis. Chest. 2008;134:237-249.
8. Lippi G, Favaloro EJ, Cervellin G. Prevention of
venous thromboembolism: focus on mechanical
prophylaxis. Semin Thromb Hemost. 2011;37:237-251.
9. Akinmoladun VI, Arotiba JT, Fasola OA,
Alonge TO, Oginni FO, Obuekwe ON. The use of
thromboembolic prophylaxis by surgeons: a
multicentre Nigerian study. Niger Postgrad Med J.
2007;14:330-335.
10. Adeleye AO, Ogbole GI. Clinical-radiological
improvement following low-tech surgical treat-
ment of an extensive cervical-medullary idiopathic
syringomyelia in a low-resource African neuro-
surgical practice. Neurosurg Rev. 2015;38:579-583
[discussion: 83].
11. Chandrasekaran S, Ariaretnam SK, Tsung J,
Dickison D. Early mobilization after total knee
replacement reduces the incidence of deep venous
thrombosis. ANZ J Surg. 2009;79:526-529.
12. Pearse EO, Caldwell BF, Lockwood RJ, Hollard J.
Early mobilisation after conventional knee
replacement may reduce the risk of postoperative
venous thromboembolism. J Bone Joint Surg Br.
2007;89:316-322.

264 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.01.069

 ORIGINAL ARTICLE
AMOS O. ADELEYE AND GABRIEL O. OGUN NEUROSURGICAL POSTOPERATIVE VENOUS THROMBOEMBOLISM

13. Khaldi A, Helo N, Schneck MJ, Origitano TC.
Venous thromboembolism: deep venous throm-
bosis and pulmonary embolism in a neurosurgical
population. J Neurosurg. 2011;114:40-46.
14. Browd SR, Ragel BT, Davis GE, Scott AM,
Skalabrin EJ, Couldwell WT. Prophylaxis for deep
venous thrombosis in neurosurgery: a review of
the literature. Neurosurg Focus. 2004;17:E1.
15. Swann KW, Black PM, Baker MF. Management of
symptomatic deep venous thrombosis and pul-
monary embolism on a neurosurgical service.
J Neurosurg. 1986;64:563-567.
16. Hamilton MG, Yee WH, Hull RD, Ghali WA.
Venous thromboembolism prophylaxis in patients
undergoing cranial neurosurgery: a systematic
review and meta-analysis. Neurosurgery. 2011;68:
571-581.
17. Danish SF, Burnett MG, Ong JG, Sonnad SS,
Maloney-Wilensky E, Stein SC. Prophylaxis for
deep venous thrombosis in craniotomy patients: a
decision analysis. Neurosurgery. 2005;56:1286-1292
[discussion: 92-94].
18. Joffe SN. Incidence of postoperative deep vein
thrombosis in neurosurgical patients. J Neurosurg.
1975;42:201-203.
19. Bucci MN, Papadopoulos SM, Chen JC,
Campbell JA, Hoff JT. Mechanical prophylaxis of
venous thrombosis in patients undergoing crani-
otomy: a randomized trial. Surg Neurol. 1989;32:
285-288.
20. Jacobs DG, Piotrowski JJ, Hoppensteadt DA,
Salvator AE, Fareed J. Hemodynamic and bri-
nolytic consequences of intermittent pneumatic
compression: preliminary results. J Trauma. 1996;
40:710-716 [discussion: 6-7].
Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 13 November 2015; accepted 14 January 2016
Citation: World Neurosurg. (2016) 89:259-265.
http://dx.doi.org/10.1016/j.wneu.2016.01.069
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter 2016 Elsevier Inc. All
rights reserved.

Introducing a NEW section in World Neurosurgery: Doing More with Less

The Doing More with Less section of World Neurosurgery will focus on the particular
needs of the lower-resource neurosurgery world, which includes most of the
world. The Section solicits submissions of news articles, commentaries, and scientific
and technical papers that relate to issues surrounding optimal patient care in resource-
challenged environments. In particular, this call for scientific and technical papers
focuses on methods for accomplishing neurosurgical goals with low-cost solutions
that are practical to implement in neurosurgical operating theaters and care
environments where minimal or basic tools and materials are available.

WORLD NEUROSURGERY 89: 259-265, MAY 2016 www.WORLDNEUROSURGERY.org 265