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Pinchuk A, Tonchev N, Stein KP, Swiatek VM, Dumitru CA, Neyazi B, Sandalcioglu IE, Rashidi A. Impact of Perioperative Acetylsalicylic Acid (ASA) Administration on Postoperative Intracranial Hemorrhage (pICH) and Thromboembolic Events in Patients with Intracranial Meningiomas. J Clin Med 2024; 13:4523. [PMID: 39124788 PMCID: PMC11313480 DOI: 10.3390/jcm13154523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/25/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024] Open
Abstract
Background: In routine medical practice, patients are increasingly using ASA for primary and secondary prevention. Although many of these patients discontinue ASA prior to elective intracranial surgery, there are limited data to support whether perioperative ASA use raises the risk of postoperative hemorrhage. This study aimed to investigate the implications of continuing or stopping ASA around the time of surgery in patients with intracranial meningiomas, focusing on postoperative hemorrhage and thromboembolic events. Methods: For this purpose, medical records and radiological images of 1862 patients who underwent cranial neurosurgical procedures for brain tumors over a decade at our neurosurgical institute were retrospectively analyzed. The risk of postoperative hemorrhage was evaluated by comparing meningioma patients who received ASA treatment with those who did not. Furthermore, we investigated other factors that influence postoperative hemorrhage and thromboembolic events, particularly in patients receiving ASA treatment. Results: A total of 422 patients diagnosed with meningiomas underwent surgical intervention. Among the patients who received ASA preoperatively, 4 out of 46 (8.69%) experienced postoperative hemorrhage requiring surgical intervention, whereas the same complication occurred in only 4 out of 376 patients (1.06%) in the non-ASA group (p = 0.007). There was no significant difference in the incidence of thromboembolic events between the two groups. Conclusions: Our analysis revealed an increased risk of postoperative hemorrhage in patients using ASA.
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Affiliation(s)
| | | | | | | | | | | | | | - Ali Rashidi
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, 39120 Magdeburg, Germany; (A.P.); (N.T.); (K.P.S.); (V.M.S.); (C.A.D.); (B.N.); (I.E.S.)
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Ullmann M, Guzman R, Mariani L, Soleman J. The effect of anti-thrombotics on the postoperative bleeding rate in patients undergoing craniotomy for brain tumor. Br J Neurosurg 2024; 38:798-804. [PMID: 34423703 DOI: 10.1080/02688697.2021.1968340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 06/15/2021] [Accepted: 08/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The peak prevalence of many brain tumors is in elderly patients. These patients are often treated with platelet inhibitors (PIs) or anticoagulants (ACs), creating a challenge for neurosurgeons concerning the perioperative management. The aim of this study is to analyze the effect of PI/AC treatment on the postoperative bleeding rates in patients undergoing craniotomy due to a brain tumor. METHODS Retrospective analysis of 415 consecutive patients undergoing craniotomy/craniectomy due to a brain tumor. Ninety-nine patients with PI/AC treatment (PI/AC group consisting of 64 PI, 29 AC, and six multiple) and 316 patients without PI/AC (control group) were primarily compared for hemorrhage rate. Secondary outcome measures were clinical outcome and mortality. The association between short preoperative discontinuation (≤5 days), early postoperative resumption time (≤5 days), as well as short total discontinuation time (≤5 days) of PI/AC and postoperative bleeding rates was analyzed. RESULTS Postoperative bleeding rates were comparable between the groups (12.2% and 13.5% in the PI/AC and control group, respectively; p=.74). The majority of bleeds were asymptomatic (85.2%). No significant difference in the postoperative mortality rate was observed (1.0% and 1.6% in the PI/AC and the control group, respectively; p=.67). Shorter discontinuation time of PI/AC was not significantly associated with higher postoperative bleeding rates (preoperative: 12.1% vs. 12.3%; p=.94, postoperative: 11.1% vs. 12.5%, respectively; p=.87, total: 16.7% vs. 12%, respectively; p=.73). CONCLUSIONS Patients treated with PI/AC undergoing craniotomy for the resection of brain tumor do not seem to have increased rates of postoperative bleeding or mortality. We did not find a significant correlation between short discontinuation time of PI/AC in the perioperative period and postoperative bleeding.
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Affiliation(s)
- Muriel Ullmann
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Luigi Mariani
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
| | - Jehuda Soleman
- Faculty of Medicine, University of Basel, Basel, Switzerland
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
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Konovalov A, Grebenev F, Artemyev A, Gadzhiagaev V, Pilipenko Y, Okishev D, Manushkova A, Eliava S, Chaurasia B. Haemorrhagic Complications After Microsurgical Treatment for Intracranial Aneurysms Under Acetylsalicylic Acid: An Impact Analysis. Cureus 2024; 16:e62622. [PMID: 39027790 PMCID: PMC11257376 DOI: 10.7759/cureus.62622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND Patients with intracranial aneurysms often have comorbidities that require them to take acetylsalicylic acid (ASA). In recent years, many patients with aneurysms have been prescribed ASA to prevent aneurysm enlargement. ASA is also prescribed to patients with intracranial aneurysms in preparation for surgical revascularization. METHODS From 2016 to 2021, 64 patients underwent microsurgical aneurysm clipping without revascularization, and an additional 20 patients underwent extracranial to intracranial (EC-IC) bypass. The following parameters were analysed: the frequency of hemorrhagic complications, the blood loss volume, the duration of surgery and inpatient treatment, the change in hemoglobin level (Hb), hematocrit (Ht), erythrocytes, and clinical outcomes according to the modified Rankin scale (mRS). RESULTS At the time of surgery, laboratory-confirmed effect of the ASA was registered in 22 patients (main group). In 42 patients, the ASA was not functional on assay (control group). Hemorrhagic complications were noted in two patients in the ASA group. In both cases, the hemorrhagic component did not exceed 15 ml in volume and did not require additional surgical interventions. Statistical analysis showed no significant differences in hemorrhagic postoperative complications. CONCLUSION Taking low doses of acetylsalicylic acid during planned microsurgical clipping of cerebral aneurysms does not affect intraoperative blood loss volume, risk of postoperative hemorrhagic complications, length of stay in the hospital, or functional outcomes.
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Affiliation(s)
- Anton Konovalov
- Cerebrovascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Fyodor Grebenev
- Neurosurgery, Burdenko National Medical Scientific Research Centre of Neurosurgery, Moscow, RUS
| | - Anton Artemyev
- Neurosurgery, Educational Institution of Higher Education Sechenov First Moscow State Medical University, Moscow, RUS
| | - Vadim Gadzhiagaev
- Neurosurgery, M.F. Vladimirsky Moscow Regional Scientific Research Clinical Institute, Moscow, RUS
| | - Yuri Pilipenko
- Neurosurgery, Burdenko National Medical Scientific Research Centre of Neurosurgery, Moscow, RUS
| | - Dmitry Okishev
- Vascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Alina Manushkova
- Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Shalva Eliava
- Vascular Surgery, Burdenko National Medical Research Center of Neurosurgery, Moscow, RUS
| | - Bipin Chaurasia
- Neurosurgery, Bhawani Hospital and Research Centre, Birgunj, NPL
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Greuter L, Rychen J, Chiappini A, Mariani L, Guzman R, Soleman J. Management of Patients undergoing Elective Craniotomy under Antiplatelet or Anticoagulation Therapy: An International Survey of Practice. J Neurol Surg A Cent Eur Neurosurg 2024; 85:246-253. [PMID: 37168014 DOI: 10.1055/s-0043-1767724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND The literature concerning the management of antiplatelet (AP) and anticoagulation (AC) medication in the perioperative phase of craniotomy remains scarce. The aim of this international survey was to investigate the current practice among neurosurgeons regarding their perioperative management of AP and AC medication. METHODS We distributed an online survey to neurosurgeons worldwide with questions concerning their perioperative practice with AP and AC medication in patients undergoing craniotomy. Descriptive statistics were performed. RESULTS A total of 130 replies were registered. The majority of responders practice neurosurgery in Europe (79%) or high-income countries (79%). Responders reported in 58.9 and 48.8% to have institutional guidelines for the perioperative management of AP and AC medication. Preoperative interruption time was reported heterogeneously for the different types of AP and AC medication with 40.4% of responders interrupting aspirin (ASA) for 4 to 6 days and 45.7% interrupting clopidogrel for 6 to 8 days. Around half of the responders considered ASA safe to be continued or resumed within 3 days for bypass (55%) or vascular (49%) surgery, but only few for skull base or other tumor craniotomies in general (14 and 26%, respectively). Three quarters of the responders (74%) did not consider AC safe to be continued or resumed early (within 3 days) for any kind of craniotomy. ASA was considered to have the lowest risk of bleeding. Nearly all responders (93%) agreed that more evidence is needed concerning AP and AC management in neurosurgery. CONCLUSION Worldwide, the perioperative management of AP and AC medication is very heterogeneous among neurosurgeons.
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Affiliation(s)
- Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Jonathan Rychen
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Alessio Chiappini
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Kulikov A, Konovalov A, Pugnaloni PP, Bilotta F. Aspirin interruption before neurosurgical interventions: A controversial problem. World J Cardiol 2024; 16:191-198. [PMID: 38690214 PMCID: PMC11056878 DOI: 10.4330/wjc.v16.i4.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/26/2024] [Accepted: 02/29/2024] [Indexed: 04/23/2024] Open
Abstract
Aspirin is widely used for primary or secondary prevention of ischemic events. At the same time, chronic aspirin consumption can affect blood clot formation during surgical intervention and increase intraoperative blood loss. This is especially important for high-risk surgery, including neurosurgery. Current European Society of Cardiology guidelines recommend aspirin interruption for at least 7 d before neurosurgical intervention, but this suggestion is not supported by clinical evidence. This narrative review presents evidence that challenges the necessity for aspirin interruption in neurosurgical patients, describes options for aspirin effect monitoring and the clinical implication of these methods, and summarizes current clinical data on bleeding risk associated with chronic aspirin therapy in neurosurgical patients, including brain tumor surgery, cerebrovascular procedures, and spinal surgery.
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Affiliation(s)
- Alexander Kulikov
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow 125047, Russia
| | - Anton Konovalov
- Department of Vascular Neurosurgery, Burdenko National Medical Research Center of Neurosurgery, Moscow 125047, Russia
| | - Pier Paolo Pugnaloni
- Department of Anesthesiology, Critical Care and Pain Medicine, University of Rome "Sapienza", Rome 00161, Italy
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, University of Rome "Sapienza", Rome 00161, Italy.
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Han HJ, Kim J, Jang CK, Kim JJ, Park KY, Park SK, Chung J, Kim YB. Perioperative Low-Dose Aspirin Management for Planned Clipping Surgery: When, How Long, and With What Precautions? Neurosurgery 2024; 94:597-605. [PMID: 37800926 DOI: 10.1227/neu.0000000000002710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/10/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Perioperative low-dose aspirin (ASA) management for open craniotomy surgery lacked information. We analyze to establish the perioperative ASA strategy to minimize both hemorrhagic and thromboembolic complications. METHODS The investigators designed a multicenter retrospective study, which included patients scheduled to have clipping surgery for unruptured intracranial aneurysm. The incidence and risk factors were analyzed for postoperative hemorrhagic complications and major cardio- and cerebrovascular events (MACCEs) within 1 month postoperation. RESULTS This study included 503 long-term ASA users of 3654 patients at three tertiary centers. The incidence of hemorrhagic complications and MACCEs was 7.4% (37/503) and 8.8% (44/503), respectively. Older age (>70 years, odds ratio [OR]: 2.928, 95% CI [1.337-6.416]), multiple aneurysms operation (OR: 2.201, 95% CI [1.017-4.765]), large aneurysm (>10 mm, OR: 4.483, 95% CI [1.485-13.533]), and ASA continuation (OR: 2.604, 95% CI [1.222-5.545]) were independent risk factors for postoperative hemorrhagic complications. Intracranial hemorrhage was the only type of hemorrhagic complication that increased in the ASA continuation group (10.6% vs 2.9%, P = .001). Between the ASA continuation and discontinuation groups, the overall incidence of MACCEs was not significantly different (log-rank P = .8). In the subgroup analysis, ASA discontinuation significantly increased the risk of MACCEs in the secondary prevention group (adjusted hazard ratio: 2.580, 95% CI [1.015-6.580]). CONCLUSION ASA continuation increased the risk of postoperative intracranial hemorrhage. Simultaneously, ASA discontinuation was the major risk factor for postoperative MACCEs in the high-risk group. Without evidence of intracranial hemorrhage, early ASA resumption was indicated (a total cessation duration <7-10 days) in the secondary prevention group.
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Affiliation(s)
- Hyun Jin Han
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Junhyung Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Chang Ki Jang
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin , Gyeonggi-do , Republic of Korea
| | - Jung-Jae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Sang Kyu Park
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul , Republic of Korea
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Kienzler JC, Fandino J. The Impact of Aspirin in Brain Tumor Surgery: To Stop or Not to Stop? Cureus 2023; 15:e51231. [PMID: 38283531 PMCID: PMC10821756 DOI: 10.7759/cureus.51231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2023] [Indexed: 01/30/2024] Open
Abstract
Given the lack of guidelines regarding perioperative management of neurosurgical patients taking antiplatelet medication, a break of aspirin intake for elective brain surgery is recommended. To the best of our knowledge, only three clinical studies have been published comparing re-bleeding rates in patients undergoing elective brain surgery with and without aspirin. We present a case of an 81-year-old woman who was admitted for elective craniotomy and brain metastases resection. She presented with a right-sided hemianopsia for > two weeks and further investigation by magnetic resonance imaging (MRI) showed the left occipital lesion. For primary cardiovascular prevention, the patient was prescribed prophylactic low-dose aspirin 100 mg. A platelet function test on the day of admission detected highly pathological values. Surgery was scheduled the next day, and aspirin intake was paused. The platelet function test was repeated the morning before surgery. Interestingly, the test showed a 20% above-normal level platelet function. Craniotomy and tumor resection were performed in a routine fashion and no increased bleeding tendency was reported intraoperatively. Postoperatively, the right-sided hemianopsia was immediately regressive. MRI performed 24 hours after surgery demonstrated a complete tumor resection without any signs of rebleeding. The patient was discharged five days after surgery without any neurological deficits. The literature is limited and guidelines are missing on the topic of management of antiplatelet medication in elective brain surgery. As confirmed by the present case and a review of the literature, elective craniotomy and tumor resection under antiplatelet medication may be considered in certain cases with risk and benefit stratification. More data and randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
| | - Javier Fandino
- Department of Neurosurgery, Hirslanden Medical Center Aarau and Zurich, Aarau, CHE
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Rychen J, Saemann A, Fingerlin T, Guzman R, Mariani L, Greuter L, Soleman J. Risks and benefits of continuation and discontinuation of aspirin in elective craniotomies: a systematic review and pooled-analysis. Acta Neurochir (Wien) 2023; 165:39-47. [PMID: 36376767 PMCID: PMC9840583 DOI: 10.1007/s00701-022-05416-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIM Discontinuation of aspirin (ASA) prior to elective craniotomies is common practice. However, patients treated with ASA for secondary prevention bear a higher risk for thromboembolic complications. Aim of this systematic review is to investigate the risks and benefits of perioperative continuation and discontinuation of ASA in elective craniotomies. METHODS PubMed and Embase databases were searched. Inclusion criteria were retro- and prospective studies, reporting hemorrhagic and thromboembolic complications in patients in whom ASA was either continued or discontinued perioperatively in elective craniotomies. We excluded shunt operations and emergency cases. The MINORS (Methodological index for non-randomized studies) score was used to quantify the methodological quality of the eligible studies. RESULTS Out of 523 publications, 7 met the eligibility criteria (cumulative cohort of 646 patients). The mean MINORS score for the comparative studies was 18.7/24 (± SD 2.07, range: 17-22) and 9/16 for the unique non-comparative study, indicating an overall weak methodological quality of the included studies. 57.1% of the patients underwent craniotomy for intra- and extra-axial tumor removal, 39.0% for bypass surgery and 3.9% for neurovascular lesions (other than bypass). In 31.0% of the cases, ASA was prescribed for primary and in 69.0% for secondary prevention. ASA was continued perioperatively in 61.8% and discontinued in 38.2% of the cases. The hemorrhagic complication rate was 3% (95% CI [0.01-0.05]) in the ASA continuation group (Con-Group) and 3% (95% CI [0.01-0.09]) in the discontinuation group (Disc-Group) (p = 0.9). The rate of thromboembolic events in the Con-Group was 3% (95% CI [0.01-0.06]) in comparison to 6% (95% CI [0.02-0.14]) in the Disc-Group (p = 0.1). CONCLUSION Perioperative continuation of ASA in elective craniotomies does not seem to be associated with an increased hemorrhagic risk. The potential beneficial effect of ASA continuation on thromboembolic events needs to be further investigated in patients under ASA for secondary prevention.
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Affiliation(s)
- Jonathan Rychen
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Attill Saemann
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Tamara Fingerlin
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, CH - 4031, Basel, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
- Department of Clinical Studies, University Hospital of Basel, Basel, Switzerland.
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Ebel F, Ullmann M, Guzman R, Soleman J. Does the discontinuation time of antiplatelet or anticoagulation treatment affect hemorrhagic complications in patients undergoing craniotomy for neurovascular lesions? Br J Neurosurg 2021; 35:619-624. [PMID: 34030525 DOI: 10.1080/02688697.2021.1929835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The number of patients treated with platelet inhibitors (PI) and/or anticoagulants (AC) in neurosurgery is increasing. The aim of this study was to analyse the effect of PI/AC discontinuation time on hemorrhagic events after craniotomy for neurovascular pathologies. METHODS The 30-day postoperative bleeding rates were retrospectively compared between short (≤5 days) and long (>5 days) discontinuation time of PI/AC before and after surgery. Kaplan-Meier survival analysis comparing time to postoperative bleeding and the effect of PI/AC discontinuation time on bleeding rates were analysed. Potential risk factors for postoperative bleeding were further analysed in uni- and multivariate analysis. RESULTS Out of 215 consecutive patients undergoing craniotomy for neurovascular lesions between January 2009 and April 2019, 23.3% were treated with PI/AC. Of these 36% (n = 18) and 20.8% (n = 10) were included in the short pre- and postoperative discontinuation group, respectively. Bleeding rates were comparable between the pre- and postoperative short and long discontinuation groups (preoperative 11.1% vs 10%, p = .659; postoperative 0% vs 13.2%, p = .566). In-hospital mortality rates and time to bleed of the groups were comparable as well. Similarly, the rate for thromboembolic events was not significantly affected by the pre- or postoperative discontinuation time of PI/AC. After multivariate analysis preoperative bleeding of the lesion was significantly associated with postoperative bleeding. CONCLUSIONS Patients with short discontinuation time of PI/AC treatment undergoing craniotomy for the treatment of neurovascular lesions do not appear to have increased rates of postoperative bleeding.
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Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Muriel Ullmann
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Basel, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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10
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Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery - should the neurosurgeon really worry about it? Neurosurg Rev 2021; 44:2889-2898. [PMID: 33495921 PMCID: PMC8490225 DOI: 10.1007/s10143-021-01476-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 11/03/2022]
Abstract
There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (> = 7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (> = 7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR = 1.0516 [0.1187; 9.3132], p = 1.000; RR = 1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p = 0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery.
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Wu J, Sun X, Liu Q, Li M, Chen S, Wang J, Wang Y, Guo P, Li X, Peng L, Jiang P, Wang N, Guo R, Yang S, Cao Y, Ning B, Liu C, Zhang F, Li J, Zhang Y, Wang S. Surgical treatment for antiplatelet intracerebral hemorrhage (SAP-ICH): protocol for a prospective cohort study of emergency surgery for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment. Chin Neurosurg J 2021; 7:5. [PMID: 33423695 PMCID: PMC7798270 DOI: 10.1186/s41016-020-00225-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 12/14/2020] [Indexed: 11/28/2022] Open
Abstract
Background Despite the capability of emergency surgery to reduce the mortality of severe spontaneous intracranial hemorrhage (SSICH) patients, the effect and safety of surgical treatment for severe spontaneous intracranial hemorrhage (SSICH) patients receiving long-term oral antiplatelet treatment (LOAPT) remains unclear. In consideration of this, the cohort study is aimed at figuring out the effect and safety of emergency surgery for SSICH patients on LOAPT. Methods As a multicenter and prospective cohort study, it will be conducted across 7 representative clinical centers. Starting in September 2019, the observation is scheduled to be completed by December 2022, with a total of 450 SSICH patients recruited. The information on clinical, radiological, and laboratory practices will be recorded objectively. All of the patients will be monitored until death or 6 months after the occurrence of primary hemorrhage. Results In this study, two comparative cohorts and an observational cohort will be set up. The primary outcome is the effect of emergency surgery, which is subject to assessment using the total mortality and comparison in the survival rate of SSICH patients on LOAPT between surgical treatment and conservative treatment. The second outcome is the safety of surgery, with the postoperative hemorrhagic complication which is compared between the operated SSICH patients on and not on LOAPT. Based on the observation of the characteristics and outcome of SSICH patients on LOAPT, the ischemic events after discontinuing LOAPT will be further addressed, and the coagulation function assessment system for operated SSICH patients on LOAPT will be established. Conclusions In this study, we will investigate the effect and safety of emergency surgery for SSICH patients on LOAPT, which will provide an evidence for management in the future. Ethics and dissemination The research protocol and informed consent in this study were approved by the Institutional Review Board of Beijing Tiantan Hospital (KY2019-096-02). The results of this study are expected to be disseminated in peer-reviewed journals in 2023. Trial registration Name: Effect and safety of surgical intervention for severe spontaneous intracerebral hemorrhage patients on long-term oral antiplatelet treatment. ChiCTR1900024406. Date of registration is July 10, 2019.
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Affiliation(s)
- Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Xinguo Sun
- Department of Neurosurgery, Binzhou People's Hospital, Binzhou, 256610, Shandong, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Maogui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Shanwen Chen
- Department of Neurosurgery, Beijing Shunyi District Hospital, No. 3 Guangming Nan Street, Shunyi District, Beijing, 101300, China
| | - Jiantao Wang
- Department of Neurosurgery, Beijing Anzhen Hospital, Capital Medical University, No.2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Youquan Wang
- Department of Neurosurgery, Beijing Pinggu District Hospital, 59 Xinping Bei Lu, Pinggu District, Beijing, China
| | - Peng Guo
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Xiong Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Lei Peng
- Department of Neurosurgery, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road, Xicheng District, Beijing, 100020, China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Nuochuan Wang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Bo Ning
- Department of Neurosurgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, 510220, Guangdong, China
| | - Cang Liu
- Department of Neurosurgery, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road, Xicheng District, Beijing, 100020, China
| | - Fuzheng Zhang
- Department of Neurosurgery, Beijing Pinggu District Hospital, 59 Xinping Bei Lu, Pinggu District, Beijing, China
| | - Jingping Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongti South Road, Chaoyang District, Beijing, 100020, China
| | - Yanan Zhang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.
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12
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Evaluating the safety of early surgery for ruptured intracranial aneurysms in patients with long-term aspirin use: a propensity score matching study. Chin Neurosurg J 2020; 6:37. [PMID: 33292864 PMCID: PMC7702666 DOI: 10.1186/s41016-020-00216-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/06/2020] [Indexed: 12/30/2022] Open
Abstract
Background Early microsurgical clipping is recommended for ruptured intracranial aneurysms to prevent rebleeding. However, dilemma frequently occurs when managing patients with current acetylsalicylic acid (aspirin) use. This study aimed to examine whether aspirin use was associated with worse outcomes after early surgery for aneurysmal subarachnoid hemorrhage (aSAH). Methods We retrieved a consecutive series of 215 patients undergoing early microsurgical clipping within 72 h after aneurysmal rupture from 2012 to 2018 in the neurosurgery department of Beijing Tiantan Hospital. The medical records of each case were reviewed. Twenty-one patients had a history of long-term aspirin use before the onset of aSAH, and 194 patients did not. To reduce confounding bias, propensity score matching (PSM) was performed to balance some characteristics of the two groups. The intraoperative blood loss, postoperative hemorrhagic events, postoperative hospital stay, and functional outcome at discharge were compared between aspirin and non-aspirin group. Results We matched all the 21 patients in aspirin group with 42 patients in non-aspirin group (1:2). Potential confounding factors were corrected between the two groups by PSM. No hospital mortality occurred after surgery. No significant differences were found in intraoperative blood loss (P = 0.540), postoperative hemorrhagic events (P > 0.999), postoperative hospital stay (P = 0.715), as well as functional outcome at discharge (P = 0.332) between the two groups. Conclusions Our preliminary results showed that long-term low-dose aspirin use was not associated with worse outcomes. Early surgery can be safe for ruptured intracranial aneurysms in patients with long-term aspirin use.
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13
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Greuter L, Ullmann M, Mariani L, Guzman R, Soleman J. Effect of preoperative antiplatelet or anticoagulation therapy on hemorrhagic complications in patients with traumatic brain injury undergoing craniotomy or craniectomy. Neurosurg Focus 2020; 47:E3. [PMID: 31675713 DOI: 10.3171/2019.8.focus19546] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is common among the elderly, often treated with antiplatelet (AP) or anticoagulation (AC) therapy, creating new challenges in neurosurgery. In contrast to elective craniotomy, in which AP/AC therapy is mostly discontinued, in TBI usually no delay in treatment can be afforded. The aim of this study was to analyze the effect of AP/AC therapy on postoperative bleeding after craniotomy/craniectomy in TBI. METHODS Postoperative bleeding rates in patients treated with AP/AC therapy (blood thinner group) and in those without AP/AC therapy (control group) were retrospectively compared. Furthermore, univariate and multivariate analyses were conducted to identify risk factors for postoperative bleeding. Lastly, a proportional Cox regression analysis comparing postoperative bleeding events within 14 days in both groups was performed. RESULTS Of 143 consecutive patients undergoing craniotomy/craniectomy for TBI between 2012 and 2017, 47 (32.9%) were under AP/AC treatment. No significant difference for bleeding events was observed in univariate (40.4% blood thinner group vs 36.5% control group; p = 0.71) or Cox proportional regression analysis (log rank χ2 = 0.29, p = 0.59). Patients with postoperative bleeding showed a significantly higher mortality rate (p = 0.035). In the univariate analysis, hemispheric lesion, acute subdural hematoma, hematological disease, greater extent of midline shift, and pupillary difference were significantly associated with a higher risk of postoperative bleeding. However, in the multivariate regression analysis none of these factors showed a significant association with postoperative bleeding. CONCLUSIONS Patients treated with AP/AC therapy undergoing craniotomy/craniectomy due to TBI do not appear to have increased rates of postoperative bleeding. Once postoperative bleeding occurs, mortality rates rise significantly.
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Affiliation(s)
- Ladina Greuter
- 1Department of Neurosurgery, University Hospital Basel, and
| | | | - Luigi Mariani
- 1Department of Neurosurgery, University Hospital Basel, and.,2Faculty of Medicine, University of Basel, Switzerland
| | - Raphael Guzman
- 1Department of Neurosurgery, University Hospital Basel, and.,2Faculty of Medicine, University of Basel, Switzerland
| | - Jehuda Soleman
- 1Department of Neurosurgery, University Hospital Basel, and.,2Faculty of Medicine, University of Basel, Switzerland
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14
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Hanalioglu S, Sahin B, Sahin OS, Kozan A, Ucer M, Cikla U, Goodman SL, Baskaya MK. Effect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study. J Neurosurg 2020; 132:1529-1538. [PMID: 30952120 DOI: 10.3171/2018.12.jns182483] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/18/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In daily practice, neurosurgeons face increasing numbers of patients using aspirin (acetylsalicylic acid, ASA). While many of these patients discontinue ASA 7-10 days prior to elective intracranial surgery, there are limited data to support whether or not perioperative ASA use heightens the risk of hemorrhagic complications. In this study the authors retrospectively evaluated the safety of perioperative ASA use in patients undergoing craniotomy for brain tumors in the largest elective cranial surgery cohort reported to date. METHODS The authors retrospectively analyzed the medical records of 1291 patients who underwent elective intracranial tumor surgery by a single surgeon from 2007 to 2017. The patients were divided into three groups based on their perioperative ASA status: 1) group 1, no ASA; 2) group 2, stopped ASA (low cardiovascular risk); and 3) group 3, continued ASA (high cardiovascular risk). Data collected included demographic information, perioperative ASA status, tumor characteristics, extent of resection (EOR), operative blood loss, any hemorrhagic and thromboembolic complications, and any other complications. RESULTS A total of 1291 patients underwent 1346 operations. The no-ASA group included 1068 patients (1112 operations), the stopped-ASA group had 104 patients (108 operations), and the continued-ASA group had 119 patients (126 operations). The no-ASA patients were significantly younger (mean age 53.3 years) than those in the stopped- and continued-ASA groups (mean 64.8 and 64.0 years, respectively; p < 0.001). Sex distribution was similar across all groups (p = 0.272). Tumor locations and pathologies were also similar across the groups, except for deep tumors and schwannomas that were relatively less frequent in the continued-ASA group. There were no differences in the EOR between groups. Operative blood loss was not significantly different between the stopped- (186 ml) and continued- (220 ml) ASA groups (p = 0.183). Most importantly, neither hemorrhagic (0.6%, 0.9%, and 0.8%, respectively; p = 0.921) nor thromboembolic (1.3%, 1.9%, and 0.8%; p = 0.779) complication rates were significantly different between the groups, respectively. In addition, the multivariate model revealed no statistically significant predictor of hemorrhagic complications, whereas male sex (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7-20.5, p = 0.005) and deep-extraaxial-benign ("skull base") tumors (OR 3.6, 95% CI 1.3-9.7, p = 0.011) were found to be independent predictors of thromboembolic complications. CONCLUSIONS In this cohort, perioperative ASA use was not associated with the increased rate of hemorrhagic complications following intracranial tumor surgery. In patients at high cardiovascular risk, ASA can safely be continued during elective brain tumor surgery to prevent potential life-threatening thromboembolic complications. Randomized clinical trials with larger sample sizes are warranted to achieve a greater statistical power.
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15
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Darkwah Oppong M, Gembruch O, Pierscianek D, Köhrmann M, Kleinschnitz C, Deuschl C, Mönninghoff C, Kaier K, Forsting M, Sure U, Jabbarli R. Post-treatment Antiplatelet Therapy Reduces Risk for Delayed Cerebral Ischemia due to Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2020; 85:827-833. [PMID: 30544176 DOI: 10.1093/neuros/nyy550] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/24/2018] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) has a strong impact on outcome of patients with aneurysmal subarachnoid hemorrhage (SAH). Positive effect of antiplatelet therapy on DCI rates has been supposed upon smaller SAH series. OBJECTIVE To analyze the benefit/risk profile of antiplatelet use in SAH patients. METHODS This retrospective case-control study was based on institutional observational cohort with 994 SAH patients treated between January 2003 and June 2016. The individuals with postcoiling antiplatelet therapy (aspirin with/without clopidogrel) were compared to a control group without antiplatelet therapy. Occurrence of DCI, major/minor bleeding events in the follow-up computed tomography scans, and favorable outcome at 6 mo after SAH (modified Rankin scale < 3) were compared in both groups. RESULTS Of 580 patients in the final analysis, 329 patients received post-treatment antiplatelet medication. There were no significant differences between the compared groups with regard to basic outcome confounders. Aspirin use was independently associated with reduced DCI risk (P < .001, adjusted odds ratio = 0.41, 95% confidence interval 0.24-0.65) and favorable outcome (P = .02, adjusted odds ratio = 1.78, 95% confidence interval 1.06-2.98). Regarding bleeding complications, aspirin was associated only with minor bleeding events (P = .02 vs P = .51 for major bleeding events). CONCLUSION Regular administration of aspirin might have a positive impact on DCI risk and outcome of SAH patients, without increasing the risk for clinically relevant bleeding events. In our SAH cohort, dual antiplatelet therapy showed no additional benefit on DCI risk, but increased the likelihood of major bleeding events.
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Affiliation(s)
- Marvin Darkwah Oppong
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | | | | | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Christoph Mönninghoff
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany
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16
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Venturini S, Fountain DM, Glancz LJ, Livermore LJ, Coulter IC, Bond S, Matta B, Santarius T, Hutchinson PJ, Brennan PM, Kolias AG. Time to surgery following chronic subdural hematoma: post hoc analysis of a prospective cohort study. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2019; 1:e000012. [PMID: 35047776 PMCID: PMC8749282 DOI: 10.1136/bmjsit-2019-000012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/26/2019] [Accepted: 10/04/2019] [Indexed: 12/03/2022] Open
Abstract
Background Chronic subdural hematoma (CSDH) is a common neurological condition; surgical evacuation is the mainstay of treatment for symptomatic patients. No clear evidence exists regarding the impact of timing of surgery on outcomes. We investigated factors influencing time to surgery and its impact on outcomes of interest. Methods Patients with CSDH who underwent burr-hole craniostomy were included. This is a subset of data from a prospective observational study conducted in the UK. Logistic mixed modelling was performed to examine the factors influencing time to surgery. The impact of time to surgery on discharge modified Rankin Scale (mRS), complications, recurrence, length of stay and survival was investigated with multivariable logistic regression analysis. Results 656 patients were included. Time to surgery ranged from 0 to 44 days (median 1, IQR 1–3). Older age, more favorable mRS on admission, high preoperative Glasgow Coma Scale score, use of antiplatelet medications, comorbidities and bilateral hematomas were associated with increased time to surgery. Time to surgery showed a significant positive association with length of stay; it was not associated with outcome, complication rate, reoperation rate, or survival on multivariable analysis. There was a trend for patients with time to surgery of ≥7 days to have lower odds of favorable outcome at discharge (p=0.061). Conclusions This study provides evidence that time to surgery does not substantially impact on outcomes following CSDH. However, increasing time to surgery is associated with increasing length of stay. These results should not encourage delaying operations for patients when they are clinically indicated.
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Affiliation(s)
- Sara Venturini
- Department of Neurosurgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Daniel M Fountain
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Ian C Coulter
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Department of Anaesthesia, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Thomas Santarius
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul M Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge & Addenbrooke's Hospital, Cambridge, UK
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Kamenova M, Mueller C, Coslovsky M, Guzman R, Mariani L, Soleman J. Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study. Trials 2019; 20:70. [PMID: 30665464 PMCID: PMC6341728 DOI: 10.1186/s13063-018-3064-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low-dose acetylsalicylic acid (ASA) in patients with chronic subdural hematoma (cSDH) represents a significant neurosurgical challenge. While continuation of ASA during the perioperative phase might increase recurrence and bleeding rates, discontinuation increases the risk of thromboembolic events. The aim of this study is to compare the postoperative recurrence and cardiovascular complication rates of patients undergoing burr-hole trepanation for cSDH with and without discontinuation of ASA. METHODS In this prospective randomized, placebo-controlled, double-blinded study we include all patients undergoing burr-hole drainage of cSDH who are under ASA treatment. The patients are randomized into two groups, one receiving ASA and the other placebo perioperatively. The study primarily seeks to compare the rate of recurrent events under ASA to that under placebo treatment. Secondary objectives are thromboembolic event rate, perioperative blood loss, postoperative anemia, intra- and postoperative blood transfusion rate, and clinical outcome. DISCUSSION To date, there is no evidence-based consensus on how to manage patients undergoing burr-hole drainage for cSDH who are under ASA treatment. Therefore, the decision to maintain or interrupt ASA treatment is based mostly on the surgeons' preference. A randomized placebo-controlled study for this frequent question is urgently needed in order to provide class I evidence for the best possible treatment of this large group of patients. TRIAL REGISTRATION ClinicalTrials.gov: NCT03120182 . Initial Release: 19.04.2017. STUDY PROTOCOL V2_23.02.2017.
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Affiliation(s)
- Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland.
| | - Christian Mueller
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 CH, Basel, Switzerland
| | - Michael Coslovsky
- Clinical Trial Unit University Hospital of Basel, Spitalstrasse 12, 4031 CH, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
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18
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Goes R, Muskens IS, Smith TR, Mekary RA, Broekman MLD, Moojen WA. Risk of aspirin continuation in spinal surgery: a systematic review and meta-analysis. Spine J 2017; 17:1939-1946. [PMID: 28823937 DOI: 10.1016/j.spinee.2017.08.238] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 07/25/2017] [Accepted: 08/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Aspirin is typically discontinued in spinal surgery because of increased risk of hemorrhagic complications. The risk of perioperative continuation of aspirin in neurosurgery needed to be evaluated. PURPOSE This study aimed to evaluate all available evidence about continuation of aspirin and to compare peri- and postoperative blood loss and complication rates between patients that continued aspirin and those who discontinued aspirin perioperatively in spinal surgery. STUDY SETTING Systematic review and meta-analysis were carried out. METHOD A meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing aspirin continuation with discontinuation were included. Studies using a combination of anticlotting agents or non-spinal procedures were excluded. Operative outcomes (blood loss and operative length) and different complications (surgical site infection [SSI]), stroke, myocardial infarction within 30 days postoperatively) were extracted. Overall prevalence and means were calculated for the reported outcomes in fixed-effects models with heterogeneity (I-squared [I2]) and effect modification (P-interaction) assessment. RESULTS Out of 1,339 studies, three case series were included in the meta-analysis. No significant differences in mean operating time were seen between the aspirin-continuing group (mean=201.8 minutes, 95% confidence interval [CI]=193.3; 210.3; I2=95.4%; 170 patients) and the aspirin-discontinuing group (mean=178.4 minutes, 95% CI=119.1; 237.6; I2=93.5%; 200 patients); (P-interaction=0.78). No significant differences in mean perioperative blood loss were seen between the aspirin-continuing group (mean=553.9 milliliters, 95% CI=468.0; 639.9; I2=83.4%; 170 patients) and the aspirin-discontinuing group (mean=538.7 milliliters, 95% CI=427.6; 649.8; I2=985.5%; 200 patients); (P-interaction=0.96). Similar non-significant differences between the two groups were found for cardiac events, stroke, and surgical site infections. CONCLUSIONS This meta-analysis showed an absence of significant differences in perioperative complications between aspirin continuation and discontinuation. Because of the paucity of included studies, further well-designed prospective trials are imperative to demonstrate potential benefit and safety.
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Affiliation(s)
- Rik Goes
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, The Netherlands.
| | - Ivo S Muskens
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands; Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Woman's Hospital, 60 Fenwood Road, 1st Floor, Boston, MA, USA
| | - Timothy R Smith
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Woman's Hospital, 60 Fenwood Road, 1st Floor, Boston, MA, USA
| | - Rania A Mekary
- Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Woman's Hospital, 60 Fenwood Road, 1st Floor, Boston, MA, USA; Department of Pharmaceutical Business and Administrative Sciences, MCPHS University, 179 Longwood Ave, Boston, MA, 02115, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands; Cushing Neurosurgery Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Woman's Hospital, 60 Fenwood Road, 1st Floor, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, 15 Parkman Street 835, Boston, MA, 02114, USA
| | - Wouter A Moojen
- Department of Neurosurgery, Haaglanden Medical Center, Lijnbaan 32, 2512VA, The Hague, The Netherlands; Department of Neurosurgery, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545AA, The Hague, The Netherlands; Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
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20
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Jabbarli R, Reinhard M, Roelz R, Shah M, Niesen WD, Kaier K, Taschner C, Weyerbrock A, Van Velthoven V. Intracerebral Hematoma Due to Aneurysm Rupture: Are There Risk Factors Beyond Aneurysm Location? Neurosurgery 2017; 78:813-20. [PMID: 26619334 DOI: 10.1227/neu.0000000000001136] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Along with subarachnoid hemorrhage (SAH), a ruptured aneurysm may also cause an intracerebral hematoma (ICH), which negatively impacts the functional outcome of SAH. OBJECTIVE To identify independent risk factors of aneurysmal ICH. METHODS Six hundred thirty-two consecutive patients with aneurysmal SAH treated at our institution from January 2005 to December 2012 were eligible for this study. Demographic parameters and preexisting comorbidities of patients, as well as various clinical and radiographic characteristics of SAH were correlated with the incidence and volume of aneurysmal ICH. RESULTS One hundred fifty-five patients (25%) had ICH on initial computed tomography with a mean volume of 26.7 mL (±26.8 mL). Occurrence and volume of ICH were associated with the location (distal anterior or middle cerebral artery >proximal anterior cerebral or internal carotid artery >posterior circulation, P < .001/P < .001) and size (>12 mm, P = .026/P < .001) of the ruptured aneurysm. Vascular risk factors independently increased the risk of ICH as well (arterial hypertension: odds ratio [OR] = 1.62, P = .032; diabetes mellitus: OR = 3.06, P = .009), while the use of aspirin (P = .037) correlated with the volume of ICH. The predictors of ICH were included into a risk score (0-9 points) that strongly predicted the occurrence of ICH (P = .01). Poor functional outcome after SAH was independently associated with the occurrence of ICH (P = .003, OR = 2.77) and its volume (P = .001, OR = 1.07 per-mL-increase). CONCLUSION Aneurysmal ICH is strongly associated with poorer functional outcome and seems to be predictable even before the bleeding event. The proposed risk factors for aneurysmal ICH require further validation and may be considered for treatment decisions regarding unruptured intracranial aneurysms. ABBREVIATIONS ACA, anterior cerebral arteryDHC, decompressive hemicraniectomyEVD, external ventricular drainageICA, internal carotid arteryICH, intracerebral hematomaMCA, middle cerebral arterymRS, modified Rankin scalePC, posterior circulationSAH, subarachnoid hemorrhageSIRS, systemic inflammatory response syndromeTCD, transcranial Doppler sonography.
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Affiliation(s)
- Ramazan Jabbarli
- *Department of Neurosurgery, University Medical Center Freiburg, Freiburg, Germany; ‡Department of Neurosurgery, University Hospital Essen, Essen, Germany; §Department of Neurology, University Medical Center Freiburg, Freiburg, Germany; ‖Institute for Medical Biometry and Medical Informatics, University Medical Center Freiburg, Freiburg, Germany; ¶Department of Neuroradiology, University Medical Center Freiburg, Freiburg, Germany
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Kamenova M, Lutz K, Schaedelin S, Fandino J, Mariani L, Soleman J. Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates? Neurosurgery 2017; 79:715-721. [PMID: 27538015 DOI: 10.1227/neu.0000000000001393] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Antiplatelet therapy in patients with chronic subdural hematoma (cSDH) presents significant neurosurgical challenges. Given the lack of guidelines regarding perioperative management with antiplatelet therapy, it is difficult to balance the patient's increased cardiovascular risk and prevalence of cSDH. OBJECTIVE To better understand the risk and recurrence rates related to resuming low-dose acetylsalicylic acid (ASA) by evaluating our patients' resumption of low-dose ASA at various times after burr-hole drainage of the hematoma. METHODS In our retrospective study, 140 consecutive patients taking low-dose ASA undergoing surgical evacuation of cSDH were included. Data included baseline characteristics and rates of recurrence, morbidity, and mortality. A multivariate logistic regression model analyzed the association between ASA resumption time and recurrence rates. RESULTS No statistically significant association was observed between early postoperative resumption of low-dose ASA and recurrence of cSDH (odds ratio, 1.01; 95% confidence interval, 1.001-1.022; P = .06). Corresponding odds ratios and risk differences for restarting ASA treatment on postoperative days 1, 7, 14, 21, 28, 35, or 42 were estimated at 1.53 and 5.9%, 1.42 and 5.1%, 1.33 and 4.1%, 1.23 and 3.2%, 1.15 and 2.2%, 1.07 and 1.1%, and 1.01 and 0.2%, respectively (P > .05). Cardiovascular event rates, surgical morbidity, and mortality did not significantly differ between patients with or without ASA therapy. CONCLUSION Given the few published studies regarding ASA use in cranial neurosurgery, our findings elucidate one issue, showing comparable recurrence rates with early or late resumption of low-dose ASA after burr-hole evacuation of cSDH. ABBREVIATIONS ASA, acetylsalicylic acidCAD, coronary artery diseaseCI, confidence intervalcSDH, chronic subdural hematomaGCS, Glasgow Coma ScalemRS, modified Rankin ScaleOR, odds ratioRD, risk difference.
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Affiliation(s)
- Maria Kamenova
- ‡Department of Neurosurgery and¶Clinical Trial Unit, University Hospital of Basel, Basel, Switzerland;§Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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Lee AT, Gagnidze A, Pan SR, Sookplung P, Nair B, Newman SF, Ben-Ari A, Zaky A, Cain K, Vavilala MS, Rozet I. Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients. Anesth Analg 2017; 125:514-520. [DOI: 10.1213/ane.0000000000002053] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Vela Vásquez R, Peláez Romero R. Aspirin and spinal haematoma after neuraxial anaesthesia: Myth or reality? Br J Anaesth 2015; 115:688-98. [DOI: 10.1093/bja/aev348] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Effects of Perioperative Acetyl Salicylic Acid on Clinical Outcomes in Patients Undergoing Craniotomy for Brain Tumor. World Neurosurg 2015; 84:41-7. [PMID: 25727304 DOI: 10.1016/j.wneu.2015.02.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/19/2015] [Accepted: 02/20/2015] [Indexed: 11/20/2022]
Abstract
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.
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications. Reg Anesth Pain Med 2015; 40:182-212. [DOI: 10.1097/aap.0000000000000223] [Citation(s) in RCA: 195] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Rossini R, Musumeci G, Visconti LO, Bramucci E, Castiglioni B, De Servi S, Lettieri C, Lettino M, Piccaluga E, Savonitto S, Trabattoni D, Capodanno D, Buffoli F, Parolari A, Dionigi G, Boni L, Biglioli F, Valdatta L, Droghetti A, Bozzani A, Setacci C, Ravelli P, Crescini C, Staurenghi G, Scarone P, Francetti L, D’Angelo F, Gadda F, Comel A, Salvi L, Lorini L, Antonelli M, Bovenzi F, Cremonesi A, Angiolillo DJ, Guagliumi G. Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies. EUROINTERVENTION 2014; 10:38-46. [DOI: 10.4244/eijv10i1a8] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.
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Affiliation(s)
- A D Oprea
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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28
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Rouine-Rapp K, McDermott MW. Perioperative management of a neurosurgical patient with a meningioma and recent coronary artery stent. J Clin Anesth 2013; 25:228-31. [DOI: 10.1016/j.jclinane.2012.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 10/14/2012] [Accepted: 11/11/2012] [Indexed: 11/24/2022]
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Perioperative management of a neurosurgical patient requiring antiplatelet therapy. J Clin Neurosci 2012; 19:1316-20. [PMID: 22784876 DOI: 10.1016/j.jocn.2011.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 12/17/2011] [Accepted: 12/28/2011] [Indexed: 11/22/2022]
Abstract
In patients who undergo neurovascular stent placement with postoperative dual antiplatelet therapy to prevent in-stent thrombosis, there is no protocol for balancing the risk of acute stent thrombosis and bleeding if urgent neurosurgical procedures are required. We detail perioperative management of dual antiplatelet therapy in a 66-year-old man with a dolichoectatic aneurysm of the basilar artery treated with a Pipeline stent. Postoperatively, the patient was placed on aspirin and clopidogrel to prevent in-stent thrombosis. One month after the procedure, his neurological status declined secondary to obstructive hydrocephalus. His condition necessitated urgent placement of a ventriculoperitoneal shunt, despite the dual antiplatelet therapy for the flow-diverting Pipeline stent. Aspirin and clopidogrel were discontinued seven days prior to the planned shunt placement. To minimize time off antiplatelet therapy, aspirin was immediately replaced with ibuprofen. Eptifibatide was then started three days prior to surgery. The ibuprofen/eptifibatide bridge was discontinued at midnight prior to surgery. Aspirin was restarted on the first postoperative day and clopidogrel was restarted on the second postoperative day. The patient tolerated shunt placement without excessive bleeding or hemorrhagic complications. During the remainder of his hospital course, no evidence of stent thrombosis or intracranial hemorrhage was noted. We conclude that management of antiplatelet prophylaxis for neurovascular stent thrombosis in patients requiring urgent neurosurgical procedures may be successfully achieved by bridging aspirin and clopidogrel with ibuprofen and eptifibatide in the preoperative period.
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Thromboprophylactic management in the neurosurgical patient with high risk for both thrombosis and intracranial bleeding. Curr Opin Anaesthesiol 2010; 23:558-63. [DOI: 10.1097/aco.0b013e32833e1589] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Boogaarts HD, Verbeek ALM, Bartels RHMA. Surgery for carpal tunnel syndrome under antiplatelet therapy. Clin Neurol Neurosurg 2010; 112:791-3. [PMID: 20727671 DOI: 10.1016/j.clineuro.2010.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Revised: 05/18/2010] [Accepted: 07/04/2010] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Antiplatelet therapy is often instituted after cardiovascular or neurological ischemic events. In general, discontinuation of the antiplatelet medication for several days is warranted previous to surgery. However, discontinuation can lead to ischemic events. For some forms of surgery, the risks of an ischemic event, and especially, its consequences do not outweigh the benefit of discontinuation of the antiplatelet therapy. Retrospective analysis was done of a cohort of patients treated for carpal tunnel syndrome with special emphasis on postoperative hemorrhage in combination with antiplatelet medication. METHODS Retrospective analysis of cohort consisting of 362 consecutive patients treated for carpal tunnel syndrome in the Neurosurgical Centre, Nijmegen was done. RESULTS In 362 patients 423 operations on carpal tunnel release were done. Thirty-one patients were on antiplatelet therapy, of which 6 did not discontinue the medication before surgery. The remaining patients stopped at least seven days before surgery. A postoperative hemorrhage did not occur in any of the 423 operations. CONCLUSION There seems no reasonable evidence that discontinuation of aspirin for carpal tunnel syndrome is justified. Bleeding complications are considered rare, moreover the impact of an ischemic cardiovascular or a cerebral event would be far more severe than that of postoperative hemorrhage in the wrist.
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Affiliation(s)
- Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Nijmegen Medical Centre, Reinier Postlaan 4, 6500 HB Nijmegen, The Netherlands.
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Guerci P, Audibert G, Mertes PM. Gestion des traitements chroniques par anticoagulants et anti-agrégants avant une neurochirurgie réglée. Neurochirurgie 2009. [DOI: 10.1016/s0028-3770(09)73175-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Anticoagulants et anti-agrégants plaquettaires dans la chirurgie hypophysaire et de la base du crâne. Neurochirurgie 2009. [DOI: 10.1016/s0028-3770(09)73178-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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The Janus face of thromboprophylaxis in patients with high risk for both thrombosis and bleeding during intracranial surgery: report of five exemplary cases. Acta Neurochir (Wien) 2009; 151:1289-94. [PMID: 19513580 DOI: 10.1007/s00701-009-0419-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 05/13/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The antithrombotic agents are usually interrupted in fear of bleeding complications before neurosurgery. However, the optimal schematic regimen of substitutive medication to prevent thromboembolic events after surgery is unsettled. METHODS We report five complex neurosurgical cases with high risk for thromboembolism requiring thromboprophylaxis during craniotomy. CLINICAL FEATURE In one patient with coronary bare metal stent and antiplatelet therapy, acetylsalicylic acid and clopidogrel was discontinued 5 and 11 days prior to surgery, respectively. Four other patients were on regular warfarin therapy due to previous deep venous thrombosis, pulmonary embolism, or mechanical aortic valve. Adjusted bridging therapy with low-molecular-weight heparin was applied in all cases. The patient with the coronary stent who was managed with reduced-dose dalteparin developed postoperative intracranial hemorrhage despite having platelet and fresh-frozen plasma transfusions, and the patient did not survive. Another patient with a history of lower-extremity deep venous thrombosis developed a postoperative intracranial hematoma but also a recurrence of left lower extremity deep venous thrombosis and had a delayed recovery. The other two patients with history of pulmonary embolism, and one patient having mechanical aortic valve and atrial fibrillation, recovered uneventfully when reduced doses of low molecular weight heparin bridging therapy were administered. CONCLUSION Our observations confirm the complexity of balancing the risks of bleeding and thrombosis in neurosurgical patients on antithrombotic medication. In these patients, the individual bleeding risk is likely minimized by the administration of reduced doses of LMWH relatively late after craniotomy and by delaying the start of warfarin after surgery.
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Gerlach R, Krause M, Seifert V, Goerlinger K. Hemostatic and hemorrhagic problems in neurosurgical patients. Acta Neurochir (Wien) 2009; 151:873-900; discussion 900. [PMID: 19557305 DOI: 10.1007/s00701-009-0409-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 10/22/2008] [Indexed: 01/10/2023]
Abstract
BACKGROUND Abnormalities of the hemostasis can lead to hemorrhage, and on the other hand to thrombosis. Intracranial neoplasms, complex surgical procedures, and head injury have a specific impact on coagulation and fibrinolysis. Moreover, the number of neurosurgical patients on medication (which interferes with platelet function and/or the coagulation systems) has increased over the past years. METHOD The objective of this review is to recall common hemostatic disorders in neurosurgical patients on the basis of the "new concept of hemostasis". Therefore the pertinent literature was searched to provide a structured and up to date manuscript about hemostasis in Neurosurgery. FINDINGS According to recent scientific publications abnormalities of the coagulation system are discussed. Pathophysiological background and the rational for specific (cost)-effective perioperative hemostatic therapy is provided. CONCLUSIONS Perturbations of hemostasis can be multifactorial and maybe encountered in the daily practice of neurosurgery. Early diagnosis and specific treatment is the prerequisite for successful treatment and good patients outcome.
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Affiliation(s)
- Ruediger Gerlach
- Department of Neurosurgery, Johann Wolfgang Goethe University, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany.
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Miyazawa T, Uozumi Y, Toyooka T, Shima K. Hemorrhage from a falx meningioma after internal use of low-dose aspirin. J Stroke Cerebrovasc Dis 2009; 17:325-7. [PMID: 18755414 DOI: 10.1016/j.jstrokecerebrovasdis.2008.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 03/03/2008] [Accepted: 03/24/2008] [Indexed: 10/21/2022] Open
Abstract
We report a case in which hemorrhage occurred in an asymptomatic falx meningioma known beforehand, after the internal use of low-dose aspirin for 16 months. Our case is the second one in which hemorrhage from a meningioma may have been induced by aspirin prophylaxis. On the other hand, aspirin may have promoted the enlargement of spontaneous hemorrhage from meningioma. Furthermore, inadequate control of hypertension may have been another cause of hemorrhage. Although it is difficult to solely attribute intratumoral hemorrhage to aspirin, we have to be careful when prescribing aspirin for patients who have asymptomatic meningioma.
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Affiliation(s)
- Takahito Miyazawa
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Japan.
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