Managing older adults with idiopathic normal pressure hydrocephalus requires careful procedural planning and individualized risk assessment. Clinicians frequently encounter the challenge of managing lumboperitoneal shunting antithrombotic therapy in patients who carry significant cardiovascular comorbidities. Withholding antiplatelet or anticoagulant agents can trigger life-threatening arterial or venous thromboembolism. Conversely, maintaining these medications introduces concerns regarding operative hemorrhage and spinal epidural hematoma. A recent single-center study investigated whether continuing antithrombotic agents on the day of surgery compromises patient outcomes.

The Challenge of Lumboperitoneal Shunting Antithrombotic Therapy

Idiopathic normal pressure hydrocephalus typically affects older individuals who often present with vascular disease. Consequently, many candidates for cerebrospinal fluid diversion receive chronic antiplatelet or anticoagulant medications. Neurosurgeons historically favored withholding antithrombotic therapy prior to elective spinal or cranial procedures. This conservative approach aimed to reduce catastrophic neuraxial hematomas. However, temporary drug cessation significantly elevates the immediate threat of ischemic stroke and coronary occlusion. Therefore, surgical teams face a delicate trade-off between perioperative bleeding and thromboembolism.

Lumboperitoneal shunting serves as a common, minimally invasive surgical alternative to ventriculoperitoneal shunting. The procedure avoids cranial penetration entirely during initial shunt catheter placement. Nevertheless, lumbar subarachnoid puncture still carries potential risks of local vessel injury and epidural bleeding. Furthermore, sudden shifts in intracranial pressure after cerebrospinal fluid diversion may precipitate delayed intracranial hemorrhage or chronic subdural collections. Clinical evidence evaluating antithrombotic continuation during lumboperitoneal shunt placement has remained scarce and inconclusive. Thus, clinicians urgently require robust real-world data to establish standardized surgical protocols for high-risk geriatric patients.

Study Design and Patient Stratification

To address this evidence gap, investigators conducted a retrospective cohort analysis at a specialized neurosurgical center. They reviewed records of consecutive adult patients diagnosed with idiopathic normal pressure hydrocephalus who underwent lumboperitoneal shunting. The researchers stratified participants into two cohorts based entirely on their antithrombotic medication status on surgery day. The Continued antithrombotic therapy group comprised patients who maintained their antiplatelet or anticoagulant regimen through the operative procedure. In contrast, the Discontinued or No therapy group included patients who either held their medications beforehand or were completely unexposed.

Overall, the investigation analyzed 203 surgical patients. Among this cohort, 164 patients (80.8%) constituted the discontinued or no antithrombotic therapy group. Meanwhile, 39 patients (19.2%) continued their prescribed antithrombotic medications without perioperative interruption. The clinical research team systematically monitored all participants across a thirty-day postoperative follow-up period. Specifically, they recorded symptomatic hemorrhagic events, chronic subdural hematoma development, and systemic thromboembolic episodes. By tracking these distinct outcomes, the authors sought to clarify whether continuing antithrombotic agents genuinely amplifies surgical danger.

Hemorrhagic Outcomes and Chronic Subdural Hematoma Rates

The primary concern regarding continued antithrombotic treatment centers on the risk of neuraxial bleeding. However, the study demonstrated an exceptionally low overall incidence of major hemorrhagic complications. Symptomatic hemorrhagic events excluding chronic subdural hematoma occurred in only 1 patient (2.6%) in the continued therapy group. Similarly, researchers recorded such complications in 2 patients (1.2%) in the discontinued or unexposed group. This comparison yielded an odds ratio of 2.13 with a wide 95% confidence interval ranging from 0.19 to 24.1. Consequently, the difference failed to reach statistical significance.

Furthermore, the investigators assessed the frequency of delayed chronic subdural hematoma within one month following shunting. Chronic subdural hematoma represents a recognized complication of cerebrospinal fluid drainage, often driven by intracranial hypotension. In the continued antithrombotic group, 2 patients (5.1%) developed chronic subdural hematoma. Meanwhile, 8 patients (4.9%) in the discontinued or no antithrombotic cohort experienced this complication. The resulting odds ratio was 1.05 with a 95% confidence interval of 0.21 to 5.17. Thus, continuing antithrombotic therapy did not visibly increase subdural fluid accumulation or hematoma progression.

Thromboembolic Complications and Ischemic Protection

Preventing arterial occlusion and venous thromboembolism remains the fundamental goal of continuing antiplatelet or anticoagulant regimens. Interrupting antithrombotic therapy during invasive procedures exposes frail patients to dangerous rebound hypercoagulability. In this surgical cohort, symptomatic thromboembolic events occurred in only 1 patient (0.6%) among the discontinued or non-user group. In contrast, none of the 39 patients who maintained their antithrombotic therapy suffered a postoperative thromboembolic complication.

Although the absolute number of ischemic events was small, this finding underscores the potential protective benefit of therapy continuation. In elderly cohorts, perioperative myocardial infarction and acute ischemic stroke carry substantial morbidity and mortality. Consequently, avoiding unnecessary drug discontinuation protects vulnerable vascular beds during surgical stress. Furthermore, the absence of thrombotic events in the continuation arm confirms that maintaining therapy does not create unexpected hemodynamic instability. Therefore, surgical teams can avoid the reflex tendency to stop critical antithrombotics when procedural hemorrhagic risks are inherently low. Nevertheless, clinicians must carefully calibrate individual cardiovascular risks against spinal puncture complexity before finalizing perioperative plans.

Clinical Implications for Surgical Decision-Making

These empirical findings provide valuable reassurance for neurosurgeons and multidisciplinary geriatric care teams. Traditionally, clinicians regarded any neuraxial procedure under active antithrombotic therapy as excessively perilous. However, modern spinal needle technologies and refined surgical techniques markedly reduce vascular trauma during catheter insertion. Consequently, the baseline risk of spinal hematoma remains low even when platelet function or coagulation factors are partially suppressed.

Moreover, avoiding medication cessation eliminates the need for complex, costly bridging anticoagulation protocols. Low-molecular-weight heparin bridging often increases bleeding hazards without offering superior protection against thromboembolism. Therefore, maintaining baseline antiplatelet therapy streamlines surgical scheduling and simplifies perioperative management. Clinicians can perform lumboperitoneal shunting without subjecting vulnerable patients to extended hospital admissions or rebound vascular risks. Nonetheless, operating surgeons must maintain meticulous intraoperative hemostasis at every step. They should exercise heightened vigilance during lumbar puncture, track cerebrospinal fluid clarity, and monitor neurological signs closely. When treating patients on potent dual antiplatelet regimens or therapeutic oral anticoagulants, teams should still formulate individualized, multidisciplinary treatment strategies.

Study Limitations and Future Research Directions

Despite these encouraging conclusions, clinicians must interpret the retrospective data within its proper context. The study cohort included a relatively modest sample of 39 patients who maintained antithrombotic medications. Because major neuraxial bleeding occurs rarely during spinal procedures, statistical power remains a prominent constraint. As the study authors appropriately highlighted, the extreme rarity of hemorrhagic events creates a fundamental obstacle for prospective clinical trials. Calculating an adequate sample size for a randomized trial would require thousands of surgical participants.

Additionally, the single-center retrospective design introduces inherent selection bias. Surgeons likely selected patients with more straightforward spinal anatomy or lower bleeding tendencies for medication continuation. Furthermore, the dataset combined various antiplatelet and anticoagulant agents into a single aggregate group. Different drug classes carry distinct pharmacokinetic profiles and varying reversal options. Therefore, future multicenter registries should differentiate between single antiplatelet agents, direct oral anticoagulants, and dual therapy. Long-term prospective registries will help clinicians establish refined, evidence-based recommendations for antithrombotic management across diverse surgical cohorts.

Frequently Asked Questions

Is it safe to continue antithrombotic therapy during lumboperitoneal shunting?

Current observational evidence indicates that continuing antithrombotic medications during lumboperitoneal shunting does not significantly increase symptomatic bleeding or chronic subdural hematoma. Although catastrophic neuraxial hemorrhage remains a theoretical concern, actual complication rates remain extremely low. Clinicians should evaluate each patient individually, balancing bleeding risks against underlying vascular threats.

Why do surgeons hesitate to stop antithrombotic agents before surgery?

Withholding antithrombotic therapy before surgery dramatically raises the risk of life-threatening thromboembolic events, including ischemic stroke, pulmonary embolism, and acute myocardial infarction. Elderly patients with idiopathic normal pressure hydrocephalus frequently carry high cardiovascular comorbidity. Therefore, temporary drug cessation can precipitate arterial thrombosis, often posing greater clinical danger than minor procedural bleeding.

Does continuing blood thinners increase the risk of subdural hematomas?

The retrospective analysis showed no significant increase in chronic subdural hematoma among patients who continued antithrombotics compared to those who stopped therapy. Chronic subdural hematomas typically develop due to cerebrospinal fluid overdrainage rather than antithrombotic exposure alone. Consequently, maintaining antithrombotic therapy did not alter postoperative hematoma incidence.

Disclaimer: This content is for informational and educational purposes only... Refer to the latest local and national guidelines for clinical practice.

References

1. Iimori T et al. Safety of continuing antithrombotic therapy during lumboperitoneal shunting for idiopathic normal pressure hydrocephalus: A single-center retrospective analysis. Clin Neurol Neurosurg. 2026 Aug. doi: 10.1016/j.clineuro.2026.109452. PMID: 42068899.


2. Nakajima M, Yamada S, Miyajima M, et al. Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus. Neurol Med Chir (Tokyo). 2021;61(2):63-97.


3. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;162(5):e207-e294.