Perioperative Thromboprophylaxis and Risk Factors for Thromboembolic Events in Meningioma Surgery: Findings From a Prospective Observational Study

Perioperative Thromboprophylaxis and Risk Factors for Thromboembolic Events in Meningioma Surgery: Findings From a Prospective Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perioperative Thromboprophylaxis and Risk Factors for Thromboembolic Events in Meningioma Surgery: Findings From a Prospective Observational Study Eva Wardenbach, Insa Prilop, Elida Benker-Hasani, Majd Alkhatib, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8114288/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study aims to evaluate the effectiveness of different thromboprophylaxis regimens, certoparin, enoxaparin, and enoxaparin combined with intermittent pneumatic stockings (IPS), in reducing thromboembolic events (TE) after meningioma surgery, and to identify patient- and procedure-specific risk factors associated with TE. Methods A prospective cohort of 877 patients undergoing surgical resection of meningiomas was analyzed. Patients were stratified into three prophylaxis groups: certoparin, enoxaparin, and enoxaparin + IPS. Clinical variables such as age, sex, comorbidities, blood loss, surgery duration, tumor location and volume were assessed. Statistical analyses included chi-square tests and ANOVA. Results The overall incidence of TE was 3.1% (n = 27). TE rates were similar across groups: certoparin (3.5%), enoxaparin (3.5%), and enoxaparin + IPS (2.6%), with no statistically significant differences (p > .05). Chronic heart disease (p = .002) and surgery duration > 200 minutes (p = .004) were identified as independent risk factors for TE. Conclusion All three thromboprophylaxis regimens demonstrated comparable efficacy in preventing postoperative TE. Although not statistically significant, the combination of enoxaparin and IPS was associated with the lowest TE rate and no fatal events. These findings support risk-adapted prophylaxis strategies in patients with elevated procedural or cardiovascular risk. Figures Figure 1 Figure 2 Introduction Meningiomas are the most common primary intracranial tumors, accounting for up to 35% of all primary brain tumors [ 11 , 22 , 34 ]. Surgical resection remains the mainstay of treatment for most cases, with generally favorable outcomes. However, perioperative complications remain a major concern, particularly thromboembolic events (TE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Meningioma patients are consistently recognized as high-risk populations for perioperative TE [ 10 ]. The reported incidence of TE in meningioma patients varies widely, ranging from 3% to 72%, depending on study design, patient selection, and detection methods [ 6 ]. Several risk factors have been proposed, including advanced age, pre-existing cardiovascular disease, longer surgery duration, greater intraoperative blood loss, and certain tumor locations. However, much of the existing evidence comes from heterogeneous cohorts that combine different brain tumor types or apply varying prophylaxis protocols. This heterogeneity limits the ability to draw meningioma-specific conclusions and hampers the development of standardized, evidence-based thromboprophylaxis guidelines for this patient population. Reported postoperative mortality from PE in neurosurgical patients can reach 50%, underscoring the need for effective preventive strategies. These findings underline the fact that meningioma patients are to be classified as a high-risk group in the context of neurosurgical interventions [ 9 , 17 , 25 – 27 ]. Thromboprophylaxis in neurosurgical patients typically involves pharma logical agents, most commonly low-molecular weight heparins (LMWH), mechanical methods such as intermittent pneumatic compression stockings (IPS), or a combination of both. While LMWH has demonstrated efficacy in reducing TE risk in high-risk surgical populations [ 4 , 26 , 28 – 31 ], its use after intracranial surgery remains controversial due to concerns about postoperative intracranial hemorrhage and the lack of formal drug approval for this indication in many countries. Moreover, differences in molecular composition between LMWH preparations may influence their clinical effectiveness, yet direct comparative data are scarce. Mechanical prophylaxis with IPS is well established and supported by multiple trials, but its additional benefit when combined with LMWH in meningioma surgery has not been clarified in prospective studies. This prospective observational study aimed to compare the effectiveness of three thromboprophylaxis regimens: certoparin, enoxaparin, and enoxaparin combined with IPS, in preventing symptomatic TE after meningioma surgery. In addition, we sought to identify patient-specific, procedure-specific, and tumor-specific risk factors associated with postoperative TE. We hypothesized that the combination of LMWH and IPS would be associated with the lowest incidence of TE and that certain clinical parameters, such as preexisting cardiovascular disease and prolonged surgery duration, would independently increase TE risk. Methods Study Design and Population This prospective observational study included a total of 877 patients diagnosed with meningioma who underwent neurosurgical treatment between 2014–2022. Eligible participants were ≥ 18 years old. Patients were not excluded for pre-existing comorbidities or a prior history of TE to ensure a representative risk profile. The cohort encompassed 15 histological subtypes (Table 1 ). Resection was performed in all cases. Demographic and clinical baseline data is summarized in Table 2 . The study was approved from the local ethics committee (reference: EK63022018). Table 1 Histological subtypes Subtype n 0 Not specified 19 1 Atypical 128 2 Fibrous 147 3 Meningothelial 389 4 Secretory 8 5 Mixed 53 6 Psammomatous 4 7 Transitional 84 8 Angiomatous 10 9 Microcystic 7 10 Clear Cell 7 11 Anaplastic 4 12 Chordoid 4 13 Multiple 7 14 Epithelioid Malignant 1 15 Lymphoplasmacytic-rich 2 Table 2 Demographic and clinical parameters stratified by thromboembolic events. Characteristics TE positive (n, %) TE negative (n, %) p-value Median age , years (IQR) 64 63 .249 Sex Female Male 20 (3.2) 9 (3.7) 611 (96.8) 237 (96.3) .679 Comorbidities Hypertonus 20 (3.9) 492 (96.1) .258 Coronary heart disease 5 (9.4) 48 (90.6) . 026 Epilepsy 8 (4.0) 191 (96.0) .503 Diabetes 5 (3.3) 145 (96.7) 1.00 Atrial fibrillation 3 (6.1) 46 (93.9) .217 Prior TE 3 (6.0) 47 (94.0) .226 Prophylaxis group Certoparin Enoxaparin Enoxaparin + IPS Overall 11 (4.3) 8 (3.5) 10 (2.6) 29 (3.3) 247 (95.7) 219 (96.5) 375 (97.4) 841 (96.7) .505 Blood loss Median blood loss, mL Blood loss > 350mL 543.21 17 (6.0) 270.00 266 (94.0) . 033 .059 Duration of surgery Median duration, min Duration > 250min 301 20 (6.2) 204 305 (93.8) < .001 < .001 Continuous variables are presented as mean ± SD or median [IQR] depending on distribution; categorical variables as number (%). Group differences were analyzed using chi-square or Kruskal–Wallis tests as appropriate. Thromboprophylaxis protocol Thromboprophylaxis protocol Three thromboprophylaxis regimens were evaluated in the study. Group 1 (n = 258) received certoparin, group 2 (n = 227) enoxaparin and both had standard compression stockings, without pneumatic compression. Group 3 (n = 386) received enoxaparin in combination with IPS. Pharmacologic prophylaxis followed institutional standards, with LMWH initiated on the first postoperative day unless contraindicated. 870/879 patients received certoparin or enoxaparin; five received fraxiparin, two heparins, and for two no data was available. A three-month postoperative period of monitoring was conducted for all patients, during which the occurrence of any cases of clinically DVT and PE was recorded. Routine screening for asymptomatic TE was not performed; only symptomatic cases were detected according to existing standard operation procedures using duplex ultrasound or computer tomography. Data Collection and Risk Factors Clinical data were extracted from patients’ electronic medical records, including anesthesia protocols, medication charts, histopathological reports and previous inpatient hospital stays. The study captured a range of demographic, clinical and surgical parameters. The data were collected by doctors, nurses, and medical students and were analyzed with a statistician to ensure rigorous evaluation. Patient-specific risk factors analyzed included: gender, age, comorbidities (epilepsy, diabetes, coronary heart disease (CHD), atrial fibrillation, hypertension, prior history of TE). Procedure-specific risk factors evaluated were duration of surgery, intraoperative blood loss, medical thromboprophylaxis administrated postoperatively and the use of IPS versus non pneumatic stockings. Tumor-specific parameters included WHO grade (I–III), histopathological subtype, volume and localization. Localization was divided into 13 subgroups (Table 3 ) and assessed volumetrically using brainlab’s “Elements” software based on preoperative contrast-enhanced T1-weighted MRI. Table 3 Tumor localization Location n 1 Non skull base – anterior - non medial (frontal/temporal) 166 2 Non skull base – posterior - non medial (parietal/occipital/temporal/cerebellum) 129 3 Non skull base – posterior - medial (parasagittal/falcine/falcotentorial/peritorcular) 61 4 Non skull base – anterior - medial (parasagittal/falcine) 72 5 Skull base – middle fossa - non medial (sphenoid wing/Meckel's cave/anterolateral face petrosum) 122 6 Skull base – middle fossa - medial (suprasellar/diaphragma/tuberculum sellae/ant/post clinoids) 38 7 Skull base – posterior fossa – non medial (cerebellopontine angle/internal acoustic meatus/jugular foramen) 48 8 Skull base – posterior fossa – medial (foramen magnum/clivus/petroclivus) 47 9 Skull base – anterior fossa – non medial (orbital roof/lateral fossa) 40 10 Skull base - anterior fossa - medial (olfactory groove/planum sphenoidale, crista galli) 91 11 Intraventricular 12 12 Intraspinal 9 13 Multiple 11 Outcome Measures The primary endpoint was the occurrence of symptomatic DVT, PE or both within three months post-surgery. The identification of DVT was based on duplex-ultrasound, while PE was diagnosed using computer-tomography. Secondary analyses assessed associations between TE and patient-, procedure-, and tumor-specific factors. Statistical Analysis All statistical evaluations were performed using IBM SPSS Statistics, version 29.0. Descriptive analyses were conducted to characterize the study population and clinical parameters. Continuous data (e.g. age, duration of surgery) are presented as medians and ranges, categorical data are shown as absolute numbers and corresponding percentages. To examine potential associations between individual risk factors and the occurrence of TE, univariate analyses were carried out. Categorical variables were assessed using Pearson's chi-square test, and continuous variables were compared with the Mann–Whitney U test. Throughout the study, a significance threshold of p < 0.05 was applied. Variables that demonstrated a statistically significant association in the univariate analysis were subsequently included in a binary logistic regression to determine independent predictors of TE. A backward elimination approach was employed to sequentially exclude non-significant factors and refine the model. The final regression results are reported as adjusted odds ratios (ORs) with 95% confidence intervals (CIs), indicating the relative risk contribution of each variable. The adequacy of the model fit was evaluated using the Nagelkerke R² and the omnibus test of model coefficients. Models with p < 0.05 were considered to have meaningful explanatory capacity. Furthermore, a decision tree analysis (Classification and Regression Tree, CART) was performed using SPSS to investigate potential patterns or interactions among predictor variables. This method facilitates the process of recursive partitioning of the dataset according to variables that most effectively differentiate between outcome groups (presence vs. absence of TE). The resulting tree structure provides an intuitive visualization of complex variable interactions and identifies key threshold values relevant for risk stratification. To reduce potential confounding due to the non-randomized allocation of thromboprophylaxis, a 1:1:1 propensity score matching was performed using nearest neighbor matching with a caliper of 0.2 standard deviations. The following covariates were included in the analysis: age, sex, CHD, diabetes, hypertension, atrial fibrillation, prior TE, surgery duration, blood loss, WHO grade, tumor volume and localization. The three prophylaxis groups were: Certoparin, enoxaparin, and enoxaparin combined with IPS. The primary outcome of interest was the occurrence of TE. Results Study population A total of 877 patients were analyzed, including 631 women (72%). The median age was 63 years (24–89 years). Detailed demographic characteristics are shown in Table 1 . Incidence and type of symptomatic thromboembolic events The overall incidence of TE was 3.3% (n = 29). 2.1% experienced symptomatic DVT, 2.2% symptomatic PE and 3.3% experienced both within the three-month postoperative period. In three documented cases, fatal TE occurred in group 1), demonstrated in Table 4 . These cases highlight that a considerable residual risk for fatal TE remained. Table 4 Lethal thromboembolic events under enoxaparin Gender Age at operation Death Histological subtype TE Comorbidities Medication Surgery duration (min) Blood loss (mL) male 73 years Postoperative day 18 Meningothelial (WHO I) PE Sepsis (Focus: Lung) Enoxaparin (Clexane) 247 0 male 74 years Postoperative day 5 Atypical (WHO II) DVT/PE Hypertension Enoxaparin (Clexane) 379 200 female 73 years Operation day Meningothelial (WHO I) DVT/PE Atrial fibrillation Enoxaparin (Clexane) 682 1700 Comparable risk for symptomatic TE with different prophylaxis regimens The patients were analyzed regarding the occurrence of symptomatic DVT or PE across the three thromboprophylaxis groups. Statistically significant differences in the incidence of DVT/PE were not identified between the prophylaxis groups: 1) 4.3%, 2) 3.5%, 3) 2.6% (p = .506) (Fig. 1 ). The likelihood ratio test (p = .506) and the linear-by-linear association test (p = .244) did not reveal any significant associations. Group 3) showed the lowest proportion of TE, without reaching statistical significance. After performing propensity score matching, n = 94 patients remained in each of the groups with comparable baseline characteristics. The incidence of TE differed numerically between the groups: 1) 4.26%, 2) 5.32%, 3) 0%. However, the difference between the groups did not reach statistical significance with p = 0.089. In the multivariable logistic regression analysis using enoxaparin as the reference group, the following odds ratios were obtained for the occurrence of a TE: certoparin: OR 1.26 (95% CI:0.44–4.04) and enoxaparin + IPS: OR 0.54 (95% CI:0.21–1.40). Bar chart illustrating the incidence of symptomatic thromboembolic events (TE) within 3 months postoperatively, stratified by thromboprophylaxis regimen. The chart displays the percentage of patients who developed deep vein thrombosis (DVT), pulmonary embolism (PE), or both (DVT + PE) in three groups: Prophylaxis groups: certoparin (group 1), enoxaparin (group 2), and enoxaparin + IPS (group 3). Although no statistically significant differences were observed between the groups, group 3 (Enoxaparin + IPS) demonstrated the lowest overall incidence of symptomatic TE. These findings suggest a potential benefit of combining pharmacological and mechanical prophylaxis in reducing postoperative thromboembolic complications Patient-specific risk factors In this cohort, univariate analysis revealed that CHD was the only patient-specific variable significantly associated with postoperative TE. Symptomatic PE occurred at a significantly higher frequency in patients with CHD (7.5%) than in patients without CHD (1.8%; p = .023). The combined endpoint of symptomatic PE and DVT also demonstrated a higher incidence in the CHD group (9.4% vs. 2.9%; p = .026). The validity of this result was confirmed through multivariate analysis, which demonstrated that CHD is an independent prognostic risk factor for both symptomatic PE (hazard ratio (HR) 5.228, 95% CI 1.619–16.897; p = .006) and DVT/PE (HR 4.030, 95% CI 1.434–11.323; p = .008). The investigation revealed that additional patient-specific factors, including age, gender, hypertension, diabetes mellitus, atrial fibrillation, epilepsy, and prior TE, exhibited no significant influence on the incidence of symptomatic TE within this cohort. Older age was not a statistically significant risk factor for TE, although affected patients were, on average, older than those without. The median age of patients with a symptomatic DVT was 63 years (p = .653), with a PE of 70 years (p = .073) and a DVT/PE 63 years (p = .249). While meningioma was more common in women (631 vs. 246 patients), female sex was not found to be a significant risk factor for symptomatic TE. Although the differences were not statistically significant, men in our cohort experienced symptomatic TE more frequently: DVT: 2.4% of men vs. 1.9% of women; PE: 2.0% of men vs. 2.2% of women, DVT/PE: 3.7% of men vs. 3.2% of women. A diagnosis of arterial hypertension was recorded in 58% of the cohort. There was no evidence that the presence of arterial hypertension increased the risk of symptomatic TE, as demonstrated by the following p-values: DVT (p = .817), PE (p = .372), and DVT/PE (p = .247). The present study found no evidence of an association between diabetes and symptomatic TE, with incidence rates for DVT (2.0% vs. 2.1%), PE (2.0% vs. 2.2%), and combined DVT/PE (3.3% vs. 3.3%) in diabetic and non-diabetic patients (all p = 1.00). Similar findings were observed in the analysis of atrial fibrillation, which demonstrated no significant association with symptomatic TE shown in the following p-values: DVT (p = .266), PE (p = .084), and DVT/PE (p = 1.00). The presence of epilepsy did not have any significant impact on the risk of symptomatic TE as well. The following ratios were examined: DVT (p = .575), PE (p = 781), and DVT/PE (p = .503). Prior TE did not affect the subsequent incidence of symptomatic TE: DVT (p = .274), PE (p = .296), and DVT/PE (p = .226). Procedure specific risk factors Of the procedure-related factors investigated, only the duration of surgery and intraoperative blood loss were found to be significant risk factors for the occurrence of symptomatic TE. Patients with a symptomatic TE had a significantly longer operation duration: DVT: 299min vs. no DVT 207min in median (p = .006), PE: 306min vs no PE 204min (p < .001). In patients with combined symptomatic TE, the duration of surgery was extended by a median of 97min (p < .001). The median volume of blood loss by patients in the cohort was 300mL. Increased blood loss during surgery has been associated with an elevated risk of symptomatic TE: Patients diagnosed with PE exhibited a median blood loss of 450mL, in contrast to the 270mL observed in patients without PE (p = .004). The median blood loss was also higher for combined events (400mL vs. 270mL; p = .033). Other factors investigated, such as positioning during surgery (72% supine, 14% prone, 13% lateral, 1% semi-sitting), showed no significant correlation with the occurrence of TE, but could not be conclusively assessed due to small subgroups. Tumor specific risk factors Decision tree analysis confirmed that surgery duration was primarily determined by tumor location, with tumor volume exerting an additional influence within each location category (supplementary). As showed in Fig. 3 , there is a correlation between tumor volume and the surgery duration (R = 0.32; p > .001). Tumors larger than 18cm³ required a median operation time of 364min, whereas tumors smaller than 4cm³ were resected in median of 200min. Small, easily accessible tumors were removed approximately 2.5 times faster than large tumors located in surgical challenging regions. The decision tree illustrates factors influencing surgery duration. Mean values, standard deviations, case numbers, and predicted values for the respective nodes are shown. The root node shows the overall mean duration of 243 minutes. The first split is determined by localization, dividing cases into skull base (anterior fossa, middle fossa, posterior fossa), multiple, spinal, intraventricular, and non-skull base (anterior, posterior) tumors. Further differentiation is based on tumor volume, with three subgroups (18,400 mm 3 . Both tumor location and tumor size significantly influence the duration of surgery, with larger tumors and certain locations (e.g., skull based) associated with longer operating times This scatter plot illustrates the relationship between tumor volume (in cm³) and surgery duration (in minutes). Each blue dot represents an individual patient case, plotting the respective tumor size against the length of the surgical procedure. A linear regression line (equation: y = 8.74 + 0.067x ) is superimposed on the data, indicating a moderate positive correlation (Pearson’s R = 0.32). This suggests that larger tumor volumes tend to be associated with longer surgery times. The x-axis ranges from 0 to 1000 minutes, and the y-axis from 0 to 250 cm³. This figure supports the hypothesis that tumor size may be a contributing factor to operative duration, which could have implications for surgical planning and resource allocation Discussion Recent research has more clarified the link between meningioma and TE. Earlier studies often lacked detailed stratifications by intervention type, surgery duration, or pathology-specific risk factors. Zhang et al.’s systematic review highlighted the relevance of these variables and the lack of data on them [ 36 ]. By focusing exclusively on patients with histologically confirmed meningiomas and analyzing both patient- and procedure-specific parameters, our study refines and extends these previous findings. The observed TE rate in our cohort is comparable to that reported in large single-center studies involving patients receiving postoperative anticoagulation without routine DVT screening. From our data, three main findings emerge: 1. CHD as the only significant patient specific risk factor. Our data identified a preexistent CHD as the only patient-specific independent risk factors for TE in our cohort. This result contrasts with our expectations, because the significance other common risk factors did not appear to be evident. We analyzed multiple patient specific parameters which are commonly known as risk factors from other studies, such as: gender [ 10 ], older age [ 2 , 3 , 9 , 10 , 13 , 20 , 21 , 24 ], prior TE [ 9 , 24 ], hypertension [ 3 ] – but all these did not emerge as significant in our cohort. An explanation could be, that the statistical power of our study is limited due to small subgroups because of the limited number of TE. It is conceivable that the standardized prophylactic regimen applied to all patients in our cohort effectively mitigated the influence of several known risk factors for TE. As a result, only particularly strong and systemic risk factors - such as CHD, which is associated with endothelial dysfunction and a prothrombotic state - remained statistically significant [ 12 , 32 ]. 2. Surgery duration: key determinant, influenced by volume / location. The duration of surgery largely depends on tumor location and volume. While these factors are difficult to modify, their impact is predictable: in our cohort, large tumors in complex regions prolonged operative time by up to 2.5-fold. Early recognition of such cases is essential to identify high-risk patients and anticipate postoperative vulnerabilities. This underscores the importance of distinguishing between modifiable and predictable risks. Even if certain factors cannot be changed, awareness allows for targeted adjustments in perioperative management. In 2013, Eisenring et al. demonstrated that patients with skull-base meningiomas benefit most from consistent thrombosis prophylaxis—findings that align with our own [ 5 ]. In their study, the average operation duration in skull-based tumors is 300-360min, in our cohort its 290min. In our view, it is not only the tumor location itself that increases the risk of thrombosis, but rather the prolonged surgical time and potentially greater tissue trauma associated with more challenging access. 3. IPS as a potential adjunct in high-risk patients. Although IPS use did not statistically significant benefit in the overall cohort, this may be due to the low incidence of TE limited statistical power. Nonetheless, both our clinical experience and prior studies support utility in selected high-risk patients. Propensity score matching allowed for balanced comparison between groups. While the differences in TE rates did not reach statistical significance, the absence of events in the enoxaparin + IPS group and the lower odds ratio suggest a potential benefit. Given the low event rate and limited sample size, these findings are exploratory and warrant confirmation in larger studies. Remarkably, since the implementation of IPS in 2019 at our institution, no fatal TE have been reported. Targeted preventive strategies, such as reserving IPS for high-risk individuals or intensifying postoperative monitoring, could offer a more individualized and resource-efficient approach. Considering the elevated risk of thromboembolic complications in neurosurgical patients, there remains substantial potential for optimization in clinical practice. This study has several limitations. Asymptomatic TE were likely undetected, since only symptomatic DVT and PE were recorded based on clinically triggered imaging, without routine postoperative screening. Prophylaxis regimens were not randomized but based on institutional drug availability and evolving protocols, introducing potential bias despite propensity score matching. Group sizes were initially unequal, and matching reduced the sample size to 94 per group, limiting statistical power. Due to drug supply limitations, no patients received certoparin combined with IPS. As a result, the mechanical prophylaxis effect cannot be assessed independently from LMWH type, limiting conclusions on potential additive effects across different LMWHs. The single-center design may limit generalizability to other settings. Lastly, the low number of symptomatic TE cases (n = 27, 3.1%) restricts the strength of subgroup analyses and may mask effects, particularly in the matched IPS group. In summary, it can be said, that in this prospective single-center study of 877 patients undergoing meningioma surgery, CHD emerged as the only independent patient-specific risk factor for postoperative TE, while prolonged surgery duration, driven by tumor size and complex anatomical location, was the key procedural determinant. Certoparin, enoxaparin, and enoxaparin combined with IPS provided comparable overall protection, although fewer and no fatal TE was observed in the enoxaparin + IPS group. No significant differences were detected between LMWH preparations, but the observed lethality signal and known pharmacological distinctions between agents and their biosimilars warrant further investigation. These findings support a risk-adapted approach to thromboprophylaxis in meningioma surgery, prioritizing high-risk patients such as those with CHD or anticipated long operative times. Combining pharmacological and mechanical methods may offer additional benefit in selected subgroups. Future multicenter studies with standardized screening protocols are needed to validate these results and to clarify the clinical relevance of LMWH formulation differences. Declarations Data availability The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Author contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by WHP and EW. The first draft of the manuscript was written by EW and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University Hospital of Dresden ( EK63022018). 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A randomized trial comparing graduated compression stockings alone or graduated compression stockings plus intermittent pneumatic compression with control. Arch Intern Med 149:679–681 Virchow RLK Thrombosis and emboli (1846–1856) /, Rudolf LK, Virchow AC, Matzdorff William R. Bell. In: Wellcome Collection. https://wellcomecollection.org/works/wcb5269f . Accessed 1 July 2025 Walenga J, Jackson C, Kessler C (2011) Low Molecular Weight Heparins Differ Substantially: Impact on Developing Biosimilar Drugs. Semin Thromb Hemost 37:322–327. 10.1055/s-0031-1274515 Wiemels J, Wrensch M, Claus EB (2010) Epidemiology and etiology of meningioma. J Neurooncol 99:307–314. 10.1007/s11060-010-0386-3 Yarabarla V, Mylarapu A, Han TJ, McGovern SL, Raza SM, Beckham TH (2023) Intracranial meningiomas: an update of the 2021 World Health Organization classifications and review of management with a focus on radiation therapy. Front Oncol 13:1137849. 10.3389/fonc.2023.1137849 Zhang Z, Cai H, Vleggeert-Lankamp CLA (2023) Thromboembolic prophylaxis in neurosurgical practice: a systematic review. Acta Neurochir 165:3119–3135. 10.1007/s00701-023-05792-3 (2015) S3-Leitlinie Prophylaxe der venösen Thromboembolie (VTE), 2. komplett überarbeitete Auflage. AWMF Leitlinien-Register Nr 003/001 (2022) Mono-Embolex® 3000 I.E. Prophylaxe Sicherheitsspritze inhixa-epar-product-information_en.pdf Additional Declarations No competing interests reported. Supplementary Files SupplementaryDecisiontree.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8114288","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":549479466,"identity":"0a578e7e-4f9f-4aa0-b9f0-c502627a2b07","order_by":0,"name":"Eva Wardenbach","email":"","orcid":"","institution":"University Hospital Carl Gustav Carus of the TU-Dresden","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"","lastName":"Wardenbach","suffix":""},{"id":549479467,"identity":"9fd3887d-97c9-4c3d-9301-9a858be4b42a","order_by":1,"name":"Insa Prilop","email":"","orcid":"","institution":"University Hospital Carl Gustav Carus of the TU-Dresden","correspondingAuthor":false,"prefix":"","firstName":"Insa","middleName":"","lastName":"Prilop","suffix":""},{"id":549479468,"identity":"4ef24f58-001c-4daf-a30b-7c5849130b31","order_by":2,"name":"Elida Benker-Hasani","email":"","orcid":"","institution":"University Hospital Carl Gustav Carus of the TU-Dresden","correspondingAuthor":false,"prefix":"","firstName":"Elida","middleName":"","lastName":"Benker-Hasani","suffix":""},{"id":549479469,"identity":"16e50c82-a4ef-4548-b3af-b47dd76e4d6f","order_by":3,"name":"Majd Alkhatib","email":"","orcid":"","institution":"University Hospital Carl Gustav Carus of the TU-Dresden","correspondingAuthor":false,"prefix":"","firstName":"Majd","middleName":"","lastName":"Alkhatib","suffix":""},{"id":549479470,"identity":"b5db9345-e57b-437e-a221-83aeda6861fc","order_by":4,"name":"Andre Sagerer","email":"","orcid":"","institution":"University Hospital Carl Gustav Carus of the TU-Dresden","correspondingAuthor":false,"prefix":"","firstName":"Andre","middleName":"","lastName":"Sagerer","suffix":""},{"id":549479471,"identity":"8393eff1-acd7-43cc-98f4-f63a6d6b2c8c","order_by":5,"name":"Ahmed Aboulhamad","email":"","orcid":"","institution":"University Hospital Carl Gustav Carus of the TU-Dresden","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Aboulhamad","suffix":""},{"id":549479472,"identity":"f2c6d78b-1a39-44ef-aa30-cba384802b50","order_by":6,"name":"Boshr Alhasan","email":"","orcid":"","institution":"University Hospital Carl Gustav Carus of the TU-Dresden","correspondingAuthor":false,"prefix":"","firstName":"Boshr","middleName":"","lastName":"Alhasan","suffix":""},{"id":549479473,"identity":"77277fcb-36c6-4493-a430-985173546f97","order_by":7,"name":"Ilker Y. 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06:56:21","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":132926,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8114288/v1/78ed12b640f92c509cb25227.html"},{"id":96967688,"identity":"438ba654-a9e8-4578-9895-89475fd7f84c","added_by":"auto","created_at":"2025-11-28 06:56:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37790,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparable risk of symptomatic thromboembolic events across different prophylaxis regimens\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8114288/v1/c99b4a317eacd2e7fab0ff8f.png"},{"id":97138350,"identity":"3a427898-ffb9-4fd5-b090-290fcc771723","added_by":"auto","created_at":"2025-12-01 09:58:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":119349,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFig. 3 Positive correlation between tumor volume and surgery duration (R = 0.32)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8114288/v1/4c76dc84d3dbf3bd8b09c669.png"},{"id":97249575,"identity":"4db70e0b-4f44-4b86-a533-c5233862fef2","added_by":"auto","created_at":"2025-12-02 13:12:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1068210,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8114288/v1/3c7d6a13-a1a6-419e-8896-f2a0f3946e0e.pdf"},{"id":97138465,"identity":"ccaa63f4-3311-4594-8b90-f68a56cb437e","added_by":"auto","created_at":"2025-12-01 09:58:53","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":71214,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryDecisiontree.docx","url":"https://assets-eu.researchsquare.com/files/rs-8114288/v1/7007e015941978f726f7082b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePerioperative Thromboprophylaxis and Risk Factors for Thromboembolic Events in Meningioma Surgery: Findings From a Prospective Observational Study \u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMeningiomas are the most common primary intracranial tumors, accounting for up to 35% of all primary brain tumors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Surgical resection remains the mainstay of treatment for most cases, with generally favorable outcomes. However, perioperative complications remain a major concern, particularly thromboembolic events (TE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Meningioma patients are consistently recognized as high-risk populations for perioperative TE [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The reported incidence of TE in meningioma patients varies widely, ranging from 3% to 72%, depending on study design, patient selection, and detection methods [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Several risk factors have been proposed, including advanced age, pre-existing cardiovascular disease, longer surgery duration, greater intraoperative blood loss, and certain tumor locations. However, much of the existing evidence comes from heterogeneous cohorts that combine different brain tumor types or apply varying prophylaxis protocols. This heterogeneity limits the ability to draw meningioma-specific conclusions and hampers the development of standardized, evidence-based thromboprophylaxis guidelines for this patient population. Reported postoperative mortality from PE in neurosurgical patients can reach 50%, underscoring the need for effective preventive strategies. These findings underline the fact that meningioma patients are to be classified as a high-risk group in the context of neurosurgical interventions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThromboprophylaxis in neurosurgical patients typically involves pharma logical agents, most commonly low-molecular weight heparins (LMWH), mechanical methods such as intermittent pneumatic compression stockings (IPS), or a combination of both. While LMWH has demonstrated efficacy in reducing TE risk in high-risk surgical populations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], its use after intracranial surgery remains controversial due to concerns about postoperative intracranial hemorrhage and the lack of formal drug approval for this indication in many countries. Moreover, differences in molecular composition between LMWH preparations may influence their clinical effectiveness, yet direct comparative data are scarce. Mechanical prophylaxis with IPS is well established and supported by multiple trials, but its additional benefit when combined with LMWH in meningioma surgery has not been clarified in prospective studies. This prospective observational study aimed to compare the effectiveness of three thromboprophylaxis regimens: certoparin, enoxaparin, and enoxaparin combined with IPS, in preventing symptomatic TE after meningioma surgery. In addition, we sought to identify patient-specific, procedure-specific, and tumor-specific risk factors associated with postoperative TE. We hypothesized that the combination of LMWH and IPS would be associated with the lowest incidence of TE and that certain clinical parameters, such as preexisting cardiovascular disease and prolonged surgery duration, would independently increase TE risk.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy Design and Population\u003c/h2\u003e\n\u003cp\u003eThis prospective observational study included a total of 877 patients diagnosed with meningioma who underwent neurosurgical treatment between 2014\u0026ndash;2022. Eligible participants were \u0026ge;\u0026thinsp;18 years old. Patients were not excluded for pre-existing comorbidities or a prior history of TE to ensure a representative risk profile. The cohort encompassed 15 histological subtypes (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Resection was performed in all cases. Demographic and clinical baseline data is summarized in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The study was approved from the local ethics committee (reference: EK63022018).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eHistological subtypes\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSubtype\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot specified\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAtypical\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e128\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFibrous\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e147\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMeningothelial\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e389\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSecretory\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMixed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e53\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePsammomatous\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTransitional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e84\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAngiomatous\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMicrocystic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eClear Cell\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnaplastic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChordoid\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMultiple\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEpithelioid Malignant\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLymphoplasmacytic-rich\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographic and clinical parameters stratified by thromboembolic events.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTE positive (n, %)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTE negative (n, %)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ep-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMedian age\u003c/strong\u003e, years (IQR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.249\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e20 (3.2)\u003c/p\u003e\n\u003cp\u003e9 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e611 (96.8)\u003c/p\u003e\n\u003cp\u003e237 (96.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.679\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHypertonus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e20 (3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e492 (96.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.258\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCoronary heart disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (9.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e48 (90.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.\u003cstrong\u003e026\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEpilepsy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (4.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e191 (96.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.503\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (3.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e145 (96.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAtrial fibrillation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (6.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46 (93.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.217\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrior TE\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (6.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47 (94.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.226\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eProphylaxis group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCertoparin\u003c/p\u003e\n\u003cp\u003eEnoxaparin\u003c/p\u003e\n\u003cp\u003eEnoxaparin\u0026thinsp;+\u0026thinsp;IPS\u003c/p\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e11 (4.3)\u003c/p\u003e\n\u003cp\u003e8 (3.5)\u003c/p\u003e\n\u003cp\u003e10 (2.6)\u003c/p\u003e\n\u003cp\u003e29 (3.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e247 (95.7)\u003c/p\u003e\n\u003cp\u003e219 (96.5)\u003c/p\u003e\n\u003cp\u003e375 (97.4)\u003c/p\u003e\n\u003cp\u003e841 (96.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.505\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eBlood loss\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedian blood loss, mL\u003c/p\u003e\n\u003cp\u003eBlood loss\u0026thinsp;\u0026gt;\u0026thinsp;350mL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e543.21\u003c/p\u003e\n\u003cp\u003e17 (6.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e270.00\u003c/p\u003e\n\u003cp\u003e266 (94.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e.\u003cstrong\u003e033\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e.059\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDuration of surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedian duration, min\u003c/p\u003e\n\u003cp\u003eDuration\u0026thinsp;\u0026gt;\u0026thinsp;250min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e301\u003c/p\u003e\n\u003cp\u003e20 (6.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e204\u003c/p\u003e\n\u003cp\u003e305 (93.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eContinuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or median [IQR] depending on distribution; categorical variables as number (%). Group differences were analyzed using chi-square or Kruskal\u0026ndash;Wallis tests as appropriate.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eThromboprophylaxis protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eThromboprophylaxis protocol\u003c/div\u003e\n\u003cp\u003eThree thromboprophylaxis regimens were evaluated in the study. Group 1 (n\u0026thinsp;=\u0026thinsp;258) received certoparin, group 2 (n\u0026thinsp;=\u0026thinsp;227) enoxaparin and both had standard compression stockings, without pneumatic compression. Group 3 (n\u0026thinsp;=\u0026thinsp;386) received enoxaparin in combination with IPS.\u003c/p\u003e\n\u003cp\u003ePharmacologic prophylaxis followed institutional standards, with LMWH initiated on the first postoperative day unless contraindicated. 870/879 patients received certoparin or enoxaparin; five received fraxiparin, two heparins, and for two no data was available. A three-month postoperative period of monitoring was conducted for all patients, during which the occurrence of any cases of clinically DVT and PE was recorded. Routine screening for asymptomatic TE was not performed; only symptomatic cases were detected according to existing standard operation procedures using duplex ultrasound or computer tomography.\u003c/p\u003e\n\u003ch3\u003eData Collection and Risk Factors\u003c/h3\u003e\n\u003cp\u003eClinical data were extracted from patients\u0026rsquo; electronic medical records, including anesthesia protocols, medication charts, histopathological reports and previous inpatient hospital stays. The study captured a range of demographic, clinical and surgical parameters. The data were collected by doctors, nurses, and medical students and were analyzed with a statistician to ensure rigorous evaluation.\u003c/p\u003e\n\u003cp\u003ePatient-specific risk factors analyzed included: gender, age, comorbidities (epilepsy, diabetes, coronary heart disease (CHD), atrial fibrillation, hypertension, prior history of TE).\u003c/p\u003e\n\u003cp\u003eProcedure-specific risk factors evaluated were duration of surgery, intraoperative blood loss, medical thromboprophylaxis administrated postoperatively and the use of IPS versus non pneumatic stockings.\u003c/p\u003e\n\u003cp\u003eTumor-specific parameters included WHO grade (I\u0026ndash;III), histopathological subtype, volume and localization. Localization was divided into 13 subgroups (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) and assessed volumetrically using brainlab\u0026rsquo;s \u0026ldquo;Elements\u0026rdquo; software based on preoperative contrast-enhanced T1-weighted MRI.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eTumor localization\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLocation\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003en\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon skull base \u0026ndash; anterior - non medial\u003c/p\u003e\n\u003cp\u003e(frontal/temporal)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e166\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon skull base \u0026ndash; posterior - non medial\u003c/p\u003e\n\u003cp\u003e(parietal/occipital/temporal/cerebellum)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e129\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon skull base \u0026ndash; posterior - medial\u003c/p\u003e\n\u003cp\u003e(parasagittal/falcine/falcotentorial/peritorcular)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e61\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon skull base \u0026ndash; anterior - medial\u003c/p\u003e\n\u003cp\u003e(parasagittal/falcine)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e72\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkull base \u0026ndash; middle fossa - non medial\u003c/p\u003e\n\u003cp\u003e(sphenoid wing/Meckel's cave/anterolateral face petrosum)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e122\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkull base \u0026ndash; middle fossa - medial\u003c/p\u003e\n\u003cp\u003e(suprasellar/diaphragma/tuberculum sellae/ant/post clinoids)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e38\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkull base \u0026ndash; posterior fossa \u0026ndash; non medial\u003c/p\u003e\n\u003cp\u003e(cerebellopontine angle/internal acoustic meatus/jugular foramen)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkull base \u0026ndash; posterior fossa \u0026ndash; medial\u003c/p\u003e\n\u003cp\u003e(foramen magnum/clivus/petroclivus)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e47\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkull base \u0026ndash; anterior fossa \u0026ndash; non medial\u003c/p\u003e\n\u003cp\u003e(orbital roof/lateral fossa)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSkull base - anterior fossa - medial\u003c/p\u003e\n\u003cp\u003e(olfactory groove/planum sphenoidale, crista galli)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e91\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntraventricular\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntraspinal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMultiple\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003eThe primary endpoint was the occurrence of symptomatic DVT, PE or both within three months post-surgery. The identification of DVT was based on duplex-ultrasound, while PE was diagnosed using computer-tomography. Secondary analyses assessed associations between TE and patient-, procedure-, and tumor-specific factors.\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eAll statistical evaluations were performed using IBM SPSS Statistics, version 29.0. Descriptive analyses were conducted to characterize the study population and clinical parameters. Continuous data (e.g. age, duration of surgery) are presented as medians and ranges, categorical data are shown as absolute numbers and corresponding percentages. To examine potential associations between individual risk factors and the occurrence of TE, univariate analyses were carried out. Categorical variables were assessed using Pearson's chi-square test, and continuous variables were compared with the Mann\u0026ndash;Whitney U test. Throughout the study, a significance threshold of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was applied. Variables that demonstrated a statistically significant association in the univariate analysis were subsequently included in a binary logistic regression to determine independent predictors of TE. A backward elimination approach was employed to sequentially exclude non-significant factors and refine the model. The final regression results are reported as adjusted odds ratios (ORs) with 95% confidence intervals (CIs), indicating the relative risk contribution of each variable. The adequacy of the model fit was evaluated using the Nagelkerke R\u0026sup2; and the omnibus test of model coefficients. Models with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered to have meaningful explanatory capacity. Furthermore, a decision tree analysis (Classification and Regression Tree, CART) was performed using SPSS to investigate potential patterns or interactions among predictor variables. This method facilitates the process of recursive partitioning of the dataset according to variables that most effectively differentiate between outcome groups (presence vs. absence of TE). The resulting tree structure provides an intuitive visualization of complex variable interactions and identifies key threshold values relevant for risk stratification. To reduce potential confounding due to the non-randomized allocation of thromboprophylaxis, a 1:1:1 propensity score matching was performed using nearest neighbor matching with a caliper of 0.2 standard deviations. The following covariates were included in the analysis: age, sex, CHD, diabetes, hypertension, atrial fibrillation, prior TE, surgery duration, blood loss, WHO grade, tumor volume and localization. The three prophylaxis groups were: Certoparin, enoxaparin, and enoxaparin combined with IPS. The primary outcome of interest was the occurrence of TE.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStudy population\u003c/h2\u003e\u003cp\u003eA total of 877 patients were analyzed, including 631 women (72%). The median age was 63 years (24\u0026ndash;89 years). Detailed demographic characteristics are shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eIncidence and type of symptomatic thromboembolic events\u003c/h3\u003e\n\u003cp\u003eThe overall incidence of TE was 3.3% (n\u0026thinsp;=\u0026thinsp;29). 2.1% experienced symptomatic DVT, 2.2% symptomatic PE and 3.3% experienced both within the three-month postoperative period. In three documented cases, fatal TE occurred in group 1), demonstrated in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. These cases highlight that a considerable residual risk for fatal TE remained.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLethal thromboembolic events under enoxaparin\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge at operation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDeath\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHistological \u003c/p\u003e\u003cp\u003esubtype\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComorbidities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMedication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSurgery \u003c/p\u003e\u003cp\u003eduration (min)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eBlood \u003c/p\u003e\u003cp\u003eloss \u003c/p\u003e\u003cp\u003e(mL)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePostoperative\u003c/p\u003e\u003cp\u003e day 18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMeningothelial \u003c/p\u003e\u003cp\u003e(WHO I)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSepsis \u003c/p\u003e\u003cp\u003e(Focus: Lung)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEnoxaparin (Clexane)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePostoperative \u003c/p\u003e\u003cp\u003eday 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAtypical \u003c/p\u003e\u003cp\u003e(WHO II)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDVT/PE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEnoxaparin (Clexane)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e379\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e200\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOperation day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMeningothelial \u003c/p\u003e\u003cp\u003e(WHO I)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDVT/PE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAtrial fibrillation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eEnoxaparin (Clexane)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e682\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e1700\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eComparable risk for symptomatic TE with different prophylaxis regimens\u003c/h2\u003e\u003cp\u003eThe patients were analyzed regarding the occurrence of symptomatic DVT or PE across the three thromboprophylaxis groups. Statistically significant differences in the incidence of DVT/PE were not identified between the prophylaxis groups: 1) 4.3%, 2) 3.5%, 3) 2.6% (p\u0026thinsp;=\u0026thinsp;.506) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe likelihood ratio test (p\u0026thinsp;=\u0026thinsp;.506) and the linear-by-linear association test (p\u0026thinsp;=\u0026thinsp;.244) did not reveal any significant associations. Group 3) showed the lowest proportion of TE, without reaching statistical significance. After performing propensity score matching, n\u0026thinsp;=\u0026thinsp;94 patients remained in each of the groups with comparable baseline characteristics. The incidence of TE differed numerically between the groups: 1) 4.26%, 2) 5.32%, 3) 0%.\u003c/p\u003e\u003cp\u003eHowever, the difference between the groups did not reach statistical significance with p\u0026thinsp;=\u0026thinsp;0.089. In the multivariable logistic regression analysis using enoxaparin as the reference group, the following odds ratios were obtained for the occurrence of a TE: certoparin: OR 1.26 (95% CI:0.44\u0026ndash;4.04) and enoxaparin\u0026thinsp;+\u0026thinsp;IPS: OR 0.54 (95% CI:0.21\u0026ndash;1.40).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBar chart illustrating the incidence of symptomatic thromboembolic events (TE) within 3 months postoperatively, stratified by thromboprophylaxis regimen. The chart displays the percentage of patients who developed deep vein thrombosis (DVT), pulmonary embolism (PE), or both (DVT\u0026thinsp;+\u0026thinsp;PE) in three groups:\u003c/p\u003e\u003cp\u003eProphylaxis groups: certoparin (group 1), enoxaparin (group 2), and enoxaparin\u0026thinsp;+\u0026thinsp;IPS (group 3). Although no statistically significant differences were observed between the groups, group 3 (Enoxaparin\u0026thinsp;+\u0026thinsp;IPS) demonstrated the lowest overall incidence of symptomatic TE. These findings suggest a potential benefit of combining pharmacological and mechanical prophylaxis in reducing postoperative thromboembolic complications\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePatient-specific risk factors\u003c/h2\u003e\u003cp\u003eIn this cohort, univariate analysis revealed that CHD was the only patient-specific variable significantly associated with postoperative TE. Symptomatic PE occurred at a significantly higher frequency in patients with CHD (7.5%) than in patients without CHD (1.8%; p\u0026thinsp;=\u0026thinsp;.023). The combined endpoint of symptomatic PE and DVT also demonstrated a higher incidence in the CHD group (9.4% vs. 2.9%; p\u0026thinsp;=\u0026thinsp;.026). The validity of this result was confirmed through multivariate analysis, which demonstrated that CHD is an independent prognostic risk factor for both symptomatic PE (hazard ratio (HR) 5.228, 95% CI 1.619\u0026ndash;16.897; p\u0026thinsp;=\u0026thinsp;.006) and DVT/PE (HR 4.030, 95% CI 1.434\u0026ndash;11.323; p\u0026thinsp;=\u0026thinsp;.008). The investigation revealed that additional patient-specific factors, including age, gender, hypertension, diabetes mellitus, atrial fibrillation, epilepsy, and prior TE, exhibited no significant influence on the incidence of symptomatic TE within this cohort. Older age was not a statistically significant risk factor for TE, although affected patients were, on average, older than those without. The median age of patients with a symptomatic DVT was 63 years (p\u0026thinsp;=\u0026thinsp;.653), with a PE of 70 years (p\u0026thinsp;=\u0026thinsp;.073) and a DVT/PE 63 years (p\u0026thinsp;=\u0026thinsp;.249). While meningioma was more common in women (631 vs. 246 patients), female sex was not found to be a significant risk factor for symptomatic TE. Although the differences were not statistically significant, men in our cohort experienced symptomatic TE more frequently: DVT: 2.4% of men vs. 1.9% of women; PE: 2.0% of men vs. 2.2% of women, DVT/PE: 3.7% of men vs. 3.2% of women. A diagnosis of arterial hypertension was recorded in 58% of the cohort. There was no evidence that the presence of arterial hypertension increased the risk of symptomatic TE, as demonstrated by the following p-values: DVT (p\u0026thinsp;=\u0026thinsp;.817), PE (p\u0026thinsp;=\u0026thinsp;.372), and DVT/PE (p\u0026thinsp;=\u0026thinsp;.247).\u003c/p\u003e\u003cp\u003eThe present study found no evidence of an association between diabetes and symptomatic TE, with incidence rates for DVT (2.0% vs. 2.1%), PE (2.0% vs. 2.2%), and combined DVT/PE (3.3% vs. 3.3%) in diabetic and non-diabetic patients (all p\u0026thinsp;=\u0026thinsp;1.00).\u003c/p\u003e\u003cp\u003eSimilar findings were observed in the analysis of atrial fibrillation, which demonstrated no significant association with symptomatic TE shown in the following p-values: DVT (p\u0026thinsp;=\u0026thinsp;.266), PE (p\u0026thinsp;=\u0026thinsp;.084), and DVT/PE (p\u0026thinsp;=\u0026thinsp;1.00). The presence of epilepsy did not have any significant impact on the risk of symptomatic TE as well. The following ratios were examined: DVT (p\u0026thinsp;=\u0026thinsp;.575), PE (p\u0026thinsp;=\u0026thinsp;781), and DVT/PE (p\u0026thinsp;=\u0026thinsp;.503). Prior TE did not affect the subsequent incidence of symptomatic TE: DVT (p\u0026thinsp;=\u0026thinsp;.274), PE (p\u0026thinsp;=\u0026thinsp;.296), and DVT/PE (p\u0026thinsp;=\u0026thinsp;.226).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eProcedure specific risk factors\u003c/h2\u003e\u003cp\u003eOf the procedure-related factors investigated, only the duration of surgery and intraoperative blood loss were found to be significant risk factors for the occurrence of symptomatic TE. Patients with a symptomatic TE had a significantly longer operation duration: DVT: 299min vs. no DVT 207min in median (p\u0026thinsp;=\u0026thinsp;.006), PE: 306min vs no PE 204min (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). In patients with combined symptomatic TE, the duration of surgery was extended by a median of 97min (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). The median volume of blood loss by patients in the cohort was 300mL. Increased blood loss during surgery has been associated with an elevated risk of symptomatic TE:\u003c/p\u003e\u003cp\u003ePatients diagnosed with PE exhibited a median blood loss of 450mL, in contrast to the 270mL observed in patients without PE (p\u0026thinsp;=\u0026thinsp;.004). The median blood loss was also higher for combined events (400mL vs. 270mL; p\u0026thinsp;=\u0026thinsp;.033). Other factors investigated, such as positioning during surgery (72% supine, 14% prone, 13% lateral, 1% semi-sitting), showed no significant correlation with the occurrence of TE, but could not be conclusively assessed due to small subgroups.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTumor specific risk factors\u003c/h2\u003e\u003cp\u003eDecision tree analysis confirmed that surgery duration was primarily determined by tumor location, with tumor volume exerting an additional influence within each location category (supplementary). As showed in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e, there is a correlation between tumor volume and the surgery duration (R\u0026thinsp;=\u0026thinsp;0.32; p\u0026thinsp;\u0026gt;\u0026thinsp;.001). Tumors larger than 18cm\u0026sup3; required a median operation time of 364min, whereas tumors smaller than 4cm\u0026sup3; were resected in median of 200min. Small, easily accessible tumors were removed approximately 2.5 times faster than large tumors located in surgical challenging regions.\u003c/p\u003e\u003cp\u003eThe decision tree illustrates factors influencing surgery duration. Mean values, standard deviations, case numbers, and predicted values for the respective nodes are shown. The root node shows the overall mean duration of 243 minutes. The first split is determined by localization, dividing cases into skull base (anterior fossa, middle fossa, posterior fossa), multiple, spinal, intraventricular, and non-skull base (anterior, posterior) tumors. Further differentiation is based on tumor volume, with three subgroups (\u0026lt;\u0026thinsp;3,950mm\u003csup\u003e3\u003c/sup\u003e; 3,950\u0026ndash;18,400 mm\u003csup\u003e3\u003c/sup\u003e; \u0026gt;18,400 mm\u003csup\u003e3\u003c/sup\u003e. Both tumor location and tumor size significantly influence the duration of surgery, with larger tumors and certain locations (e.g., skull based) associated with longer operating times\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThis scatter plot illustrates the relationship between tumor volume (in cm\u0026sup3;) and surgery duration (in minutes). Each blue dot represents an individual patient case, plotting the respective tumor size against the length of the surgical procedure. A linear regression line (equation: \u003cem\u003ey\u0026thinsp;=\u0026thinsp;8.74\u0026thinsp;+\u0026thinsp;0.067x\u003c/em\u003e) is superimposed on the data, indicating a moderate positive correlation (Pearson\u0026rsquo;s R\u0026thinsp;=\u0026thinsp;0.32). This suggests that larger tumor volumes tend to be associated with longer surgery times. The x-axis ranges from 0 to 1000 minutes, and the y-axis from 0 to 250 cm\u0026sup3;. This figure supports the hypothesis that tumor size may be a contributing factor to operative duration, which could have implications for surgical planning and resource allocation\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eRecent research has more clarified the link between meningioma and TE. Earlier studies often lacked detailed stratifications by intervention type, surgery duration, or pathology-specific risk factors. Zhang et al.\u0026rsquo;s systematic review highlighted the relevance of these variables and the lack of data on them [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. By focusing exclusively on patients with histologically confirmed meningiomas and analyzing both patient- and procedure-specific parameters, our study refines and extends these previous findings. The observed TE rate in our cohort is comparable to that reported in large single-center studies involving patients receiving postoperative anticoagulation without routine DVT screening.\u003c/p\u003e\n\u003cp\u003eFrom our data, three main findings emerge:\u003c/p\u003e\n\u003cp\u003e1. CHD as the only significant patient specific risk factor.\u003c/p\u003e\n\u003cp\u003eOur data identified a preexistent CHD as the only patient-specific independent risk factors for TE in our cohort. This result contrasts with our expectations, because the significance other common risk factors did not appear to be evident.\u003c/p\u003e\n\u003cp\u003eWe analyzed multiple patient specific parameters which are commonly known as risk factors from other studies, such as: gender [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e], older age [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], prior TE [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], hypertension [\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e] \u0026ndash; but all these did not emerge as significant in our cohort. An explanation could be, that the statistical power of our study is limited due to small subgroups because of the limited number of TE. It is conceivable that the standardized prophylactic regimen applied to all patients in our cohort effectively mitigated the influence of several known risk factors for TE. As a result, only particularly strong and systemic risk factors - such as CHD, which is associated with endothelial dysfunction and a prothrombotic state - remained statistically significant [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e2. Surgery duration: key determinant, influenced by volume / location.\u003c/p\u003e\n\u003cp\u003eThe duration of surgery largely depends on tumor location and volume. While these factors are difficult to modify, their impact is predictable: in our cohort, large tumors in complex regions prolonged operative time by up to 2.5-fold. Early recognition of such cases is essential to identify high-risk patients and anticipate postoperative vulnerabilities. This underscores the importance of distinguishing between modifiable and predictable risks. Even if certain factors cannot be changed, awareness allows for targeted adjustments in perioperative management. In 2013, Eisenring et al. demonstrated that patients with skull-base meningiomas benefit most from consistent thrombosis prophylaxis\u0026mdash;findings that align with our own [\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]. In their study, the average operation duration in skull-based tumors is 300-360min, in our cohort its 290min. In our view, it is not only the tumor location itself that increases the risk of thrombosis, but rather the prolonged surgical time and potentially greater tissue trauma associated with more challenging access.\u003c/p\u003e\n\u003cp\u003e3. IPS as a potential adjunct in high-risk patients.\u003c/p\u003e\n\u003cp\u003eAlthough IPS use did not statistically significant benefit in the overall cohort, this may be due to the low incidence of TE limited statistical power. Nonetheless, both our clinical experience and prior studies support utility in selected high-risk patients. Propensity score matching allowed for balanced comparison between groups. While the differences in TE rates did not reach statistical significance, the absence of events in the enoxaparin\u0026thinsp;+\u0026thinsp;IPS group and the lower odds ratio suggest a potential benefit. Given the low event rate and limited sample size, these findings are exploratory and warrant confirmation in larger studies. Remarkably, since the implementation of IPS in 2019 at our institution, no fatal TE have been reported. Targeted preventive strategies, such as reserving IPS for high-risk individuals or intensifying postoperative monitoring, could offer a more individualized and resource-efficient approach. Considering the elevated risk of thromboembolic complications in neurosurgical patients, there remains substantial potential for optimization in clinical practice.\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. Asymptomatic TE were likely undetected, since only symptomatic DVT and PE were recorded based on clinically triggered imaging, without routine postoperative screening. Prophylaxis regimens were not randomized but based on institutional drug availability and evolving protocols, introducing potential bias despite propensity score matching. Group sizes were initially unequal, and matching reduced the sample size to 94 per group, limiting statistical power. Due to drug supply limitations, no patients received certoparin combined with IPS. As a result, the mechanical prophylaxis effect cannot be assessed independently from LMWH type, limiting conclusions on potential additive effects across different LMWHs. The single-center design may limit generalizability to other settings. Lastly, the low number of symptomatic TE cases (n\u0026thinsp;=\u0026thinsp;27, 3.1%) restricts the strength of subgroup analyses and may mask effects, particularly in the matched IPS group.\u003c/p\u003e\n\u003cp\u003eIn summary, it can be said, that in this prospective single-center study of 877 patients undergoing meningioma surgery, CHD emerged as the only independent patient-specific risk factor for postoperative TE, while prolonged surgery duration, driven by tumor size and complex anatomical location, was the key procedural determinant. Certoparin, enoxaparin, and enoxaparin combined with IPS provided comparable overall protection, although fewer and no fatal TE was observed in the enoxaparin\u0026thinsp;+\u0026thinsp;IPS group. No significant differences were detected between LMWH preparations, but the observed lethality signal and known pharmacological distinctions between agents and their biosimilars warrant further investigation. These findings support a risk-adapted approach to thromboprophylaxis in meningioma surgery, prioritizing high-risk patients such as those with CHD or anticipated long operative times. Combining pharmacological and mechanical methods may offer additional benefit in selected subgroups. Future multicenter studies with standardized screening protocols are needed to validate these results and to clarify the clinical relevance of LMWH formulation differences.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003e\u003cu\u003eData availability\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eAuthor contributions\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by WHP and EW. The first draft of the manuscript was written by EW and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eCompeting Interests\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eEthics approval\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University Hospital of Dresden (\u003c/em\u003eEK63022018).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eInformed Consent Statement\u003c/u\u003e\u003c/em\u003e\u003cbr\u003e\u0026nbsp;All patients provided written informed consent for the use of their clinical data for research purposes as part of the treatment contract with the University Hospital Dresden.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCaroli M, Locatelli M, Prada F (2005) Surgery for intracranial meningiomas in the elderly: a clinical\u0026mdash;radiological grading system as a predictor of outcome in: Journal of Neurosurgery Volume 102 Issue 2 Journals. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://thejns.org/view/journals/j-neurosurg/102/2/article-p290.xml\u003c/span\u003e\u003cspan address=\"https://thejns.org/view/journals/j-neurosurg/102/2/article-p290.xml\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 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Prophylaxe Sicherheitsspritze\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003einhixa-epar-product-information_en.pdf\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8114288/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8114288/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose\u003c/p\u003e\n\u003cp\u003eThis study aims to evaluate the effectiveness of different thromboprophylaxis regimens, certoparin, enoxaparin, and enoxaparin combined with intermittent pneumatic stockings (IPS), in reducing thromboembolic events (TE) after meningioma surgery, and to identify patient- and procedure-specific risk factors associated with TE.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eA prospective cohort of 877 patients undergoing surgical resection of meningiomas was analyzed. Patients were stratified into three prophylaxis groups: certoparin, enoxaparin, and enoxaparin + IPS. Clinical variables such as age, sex, comorbidities, blood loss, surgery duration, tumor location and volume were assessed. Statistical analyses included chi-square tests and ANOVA.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eThe overall incidence of TE was 3.1% (n = 27). TE rates were similar across groups: certoparin (3.5%), enoxaparin (3.5%), and enoxaparin + IPS (2.6%), with no statistically significant differences (p \u0026gt; .05). Chronic heart disease (p = .002) and surgery duration \u0026gt; 200 minutes (p = .004) were identified as independent risk factors for TE.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eAll three thromboprophylaxis regimens demonstrated comparable efficacy in preventing postoperative TE. Although not statistically significant, the combination of enoxaparin and IPS was associated with the lowest TE rate and no fatal events. These findings support risk-adapted prophylaxis strategies in patients with elevated procedural or cardiovascular risk.\u003c/p\u003e","manuscriptTitle":"Perioperative Thromboprophylaxis and Risk Factors for Thromboembolic Events in Meningioma Surgery: Findings From a Prospective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-28 06:56:15","doi":"10.21203/rs.3.rs-8114288/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7b496667-ba03-4dfe-a906-58b756227bd5","owner":[],"postedDate":"November 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-02T01:38:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-28 06:56:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8114288","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8114288","identity":"rs-8114288","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}