Elsevier

World Neurosurgery

Volume 84, Issue 1, July 2015, Pages 41-47
World Neurosurgery

Original Article
Effects of Perioperative Acetyl Salicylic Acid on Clinical Outcomes in Patients Undergoing Craniotomy for Brain Tumor

https://doi.org/10.1016/j.wneu.2015.02.016Get rights and content

Objective

To evaluate the safety of continuing acetyl salicylic acid (ASA) in patients undergoing brain tumor resection. Many patients are on antiplatelet agents that are withheld before elective neurosurgical procedures to reduce bleeding risk. Cessation of ASA in patients with cardiovascular disease is associated with a known increased risk of thrombotic events, especially in patients with coronary stents.

Methods

The medical records of patients who underwent surgical resection of a brain tumor at the University of Florida from 2010 to 2014 were evaluated. The patients were separated into groups based on preoperative ASA use and whether or not it was stopped before surgery. Patients were evaluated for thrombotic complications, postoperative hemorrhage, estimated blood loss, length of hospital stay, and discharge disposition.

Results

Of the 452 patients analyzed, 368 patients were not on chronic ASA therapy, 55 patients had their ASA discontinued before surgery, and 28 patients were continued on ASA perioperatively. The patients on preoperative ASA were comparable on all collected demographic variables. There were no statistical differences detected between the groups for outcomes including bleeding complications, need for reoperation, or thrombotic complications.

Conclusions

In this analysis, perioperative low dose ASA use was not associated with increased risk of perioperative complications.

Introduction

The management of antiplatelet agents is a serious therapeutic dilemma in neurosurgical patients. The devastating and potentially fatal sequelae of a hemorrhagic complication from a craniotomy are well-known (16). Therefore, most neurosurgeons commonly stop the administration of all antiplatelet agents several days before elective cranial surgery. An increasing number of patients are taking chronic low dose acetyl salicylic acid (ASA) 9, 10 because it has been shown to have a clear benefit in secondary prevention of cardiovascular events and possible benefit in primary prevention as well (4). In addition, patients with coronary stents are often on dual antiplatelet therapy with ASA and another agent. The American College of Cardiology/American Heart Association guidelines (14) recommend uninterrupted dual antiplatelet therapy with ASA plus a thienopyridine (clopidogrel, prasugrel, or ticagrelor) for 6 weeks after bare metal stent placement and 12 months after drug-eluting stent (DES) placement to prevent stent thrombosis. Thereafter, ASA should be continued lifelong in most patients to prevent late stent thrombosis.

In most cases, patients with brain tumors need timely surgical treatment that cannot be delayed to meet these antiplatelet guidelines. If antiplatelet therapy is continued during surgery, the risk of a hemorrhagic complication may increase 5, 17. Of patients who suffer a postoperative hemorrhage, more than half will die or live with severe disability (17). Therefore, almost uniformly, patients with brain tumor on ASA will have their ASA stopped before surgical resection. This strategy potentially decreases the risk of postoperative hemorrhage, but increases the risk of thrombotic cardiovascular events. At present, little evidence exists to inform the management of neurosurgical patients on antiplatelet agents.

Quantifying the risks associated with continuing or discontinuing antiplatelet agents in the perioperative period is critical. The purpose of this study is to evaluate the safety of continuing ASA in patients undergoing brain tumor resection by comparing outcomes in patients who were kept on ASA perioperatively with patients whose ASA was discontinued before surgery.

Section snippets

Patients, Inclusion/Exclusion Criteria, and Study Variables

Institutional Review Board approval was obtained at the University of Florida. Admissions of patients with brain tumors to University of Florida Health between 2010 and 2014 were identified using the neurosurgery billing database and the following International Classification of Diseases, 9th Revision (22) codes: 191.0-.9, 225.0-.2, 225.9, 198.3, 192.1, 239.6, 237.1, 237.5-.6, and 227.3-.4. From the list obtained, patients who underwent a supratentorial or infratentorial craniotomy for tumor or

Results

Overall, 452 patients with brain tumors met the inclusion criteria. Of these patients, 368 were not on ASA therapy, 55 had their ASA discontinued before surgery (27 in group 2 and 28 in group 3), and 28 patients had their ASA continued in the perioperative period. Table 1 shows the demographic data and medical comorbidities in these patient groups. Not surprisingly, patients on ASA were more likely to be older, male, and have more comorbidities compared with patients not on ASA. Overall, there

Discussion

In this retrospective cohort analysis, no statistically significant differences were found in postoperative complications or discharge status in patients whose ASA was continued at the time of surgery for a brain tumor. However, there are interesting trends to note. Patients on ASA at the time of surgery had a trend for a higher EBL but a zero incidence of postoperative thrombotic events. Important, ASA was not associated with increased risk of postoperative hematoma or need for reoperation.

Conclusion

In the present study, continuing ASA at the time of craniotomy was not associated with increased risk of postoperative complication. Decisions regarding antiplatelet therapy in the perioperative period would be best made in a multidisciplinary fashion, including consultation with a cardiologist. In addition, tailored therapy with the use of point of care platelet functional assays may help guide these decisions. Additional investigation into this area in a prospective fashion is warranted.

Acknowledgments

We extend our thanks to Frances Skipper for providing assistance with data retrieval and Nancy Lanni for editorial assistance.

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    Conflict of interest statement: The project was partly funded by the UF Medical Science Research Program and the Lawrence M. Goodman research fellowship.

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