Original ArticleEffects of Perioperative Acetyl Salicylic Acid on Clinical Outcomes in Patients Undergoing Craniotomy for Brain Tumor
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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Morbidity and Mortality After Burr Hole Craniostomy Versus Craniotomy for Chronic Subdural Hematoma Evacuation: A Single-Center Experience
2020, World NeurosurgeryCitation Excerpt :Aspirin use is a well-known risk factor for the development of subdural hematomas and has been associated with a greater risk of subdural hematoma recurrence postoperatively.18-22 However, a recent study of craniotomy for brain tumor resection reported that aspirin was not a risk factor for postoperative complications, including hematoma.23 Similarly, another study of the resumption of low-dose aspirin after burr hole evacuation of cSDH showed comparable recurrence rates with early or late resumption of low-dose aspirin and no significant association between low-dose aspirin resumption and the recurrence of cSDH.24
Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018
2019, Revista Espanola de Anestesiologia y ReanimacionManagement of Aneurysmal Subarachnoid Hemorrhage Patients with Antiplatelet Use Before the Initial Hemorrhage: An International Survey
2018, World NeurosurgeryCitation Excerpt :Intracranial surgery, in comparison with other noncranial surgeries, is associated more often with severe complications because of postoperative hemorrhages; therefore, coagulation need to be optimal. Interestingly, in patients undergoing craniotomy for a brain tumor, perioperative low-dose aspirin use was not associated with an increased risk of bleeding complications or need for surgical revision.22 One study23 showed that aspirin administration in patients with increased risk for endovascular complications significantly decreased the rate of periprocedural thromboembolic events.
Perioperative Management of Cardiovascular Medications
2018, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Another multicenter, randomized, placebo-controlled trial also confirmed the safety of aspirin starting 10 days before surgery in terms of major thrombotic and adverse bleeding events occurring within the first 30 postoperative days.123 Furthermore, the safety of aspirin has been demonstrated for surgical interventions that traditionally are considered to be associated with high bleeding risks such as neurosurgery124 and urologic surgery.125 However, conflicting data demonstrating an increased risk of hemorrhagic complications also exist, although these generally are found in works published in the 1990s126 and may be considered as outdated.
Perioperative Aspirin in Cardiac and Noncardiac Surgery
2017, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :A retrospective review of 6,668 neurosurgical surgeries from 1989 to 1993 found that 43% of patients with postoperative intracranial hematoma had been treated with an antiplatelet agent in the preoperative period.33 However, a retrospective review by Rahman et al11 of 452 contemporary patients suggested that preoperative aspirin can be administered safely before intracranial neurosurgery. Investigators found no differences in perioperative estimated blood loss, postoperative hematoma, reoperation for bleeding, or thromboembolic complications in the aspirin- and nonaspirin-treated populations.11
Conflict of interest statement: The project was partly funded by the UF Medical Science Research Program and the Lawrence M. Goodman research fellowship.