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Tonchev N, Pinchuk A, Dumitru CA, Neyazi B, Swiatek VM, Stein KP, Sandalcioglu IE, Rashidi A. Postoperative Acute Intracranial Hemorrhage and Venous Thromboembolism in Patients with Brain Metastases Receiving Acetylsalicylic Acid Perioperatively. Curr Oncol 2024; 31:4599-4612. [PMID: 39195326 DOI: 10.3390/curroncol31080343] [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: 07/11/2024] [Revised: 07/31/2024] [Accepted: 08/09/2024] [Indexed: 08/29/2024] Open
Abstract
Cranial operations are associated with a high risk of postoperative intracranial hemorrhage (pICH) and venous thromboembolic events, along with increased mortality and morbidity. With the use of acetylsalicylic acid (ASA) for prophylaxis becoming more prevalent, the risk of bleeding when ASA is administered preoperatively is unknown, as are the effects of discontinuation upon the occurrence of thromboembolic events, especially in societies with aging demographics. To address these questions, a retrospective analysis was performed using medical records and radiological images of 1862 patients subjected to brain tumor surgery over a decade in our department. The risk of pICH was compared in patients with metastases receiving ASA treatment versus patients not receiving ASA treatment. The occurrence of venous thromboembolic events after surgery was also evaluated. The study group consisted of 365 patients with different types of brain metastases. In total, 20 patients suffered pICH and 7 of these were associated with clinical neurological deterioration postoperatively. Of the 58 patients who took ASA preoperatively, 2 patients experienced pICH, compared with 5 patients in the non-ASA impact group (p = 0.120). Patients who took ASA were not at significantly higher risk of pICH and therefore a worse outcome compared to the group without ASA. Therefore, these data suggest that in patients at high cardiovascular risk, ASA can be safely continued during elective brain tumor surgery.
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Affiliation(s)
- Nikolay Tonchev
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Anatoli Pinchuk
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Claudia A Dumitru
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Belal Neyazi
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Vanessa Magdalena Swiatek
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Klaus Peter Stein
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Ibrahim Erol Sandalcioglu
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
| | - Ali Rashidi
- Department of Neurosurgery, Otto-von-Guericke-University Magdeburg, Leipziger Straße 44, 39120 Magdeburg, Germany
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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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Yang J, Wang K, Han C, Liu Q, Zhang S, Wu J, Jiang P, Yang S, Guo R, Mo S, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. Preoperative antiplatelet therapy may be a risk factor for postoperative ischemic complications in intracranial hemorrhage patients. Int J Neurosci 2024; 134:899-905. [PMID: 36503400 DOI: 10.1080/00207454.2022.2157724] [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: 01/14/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hemorrhage (ICH) patients are still at risk of postoperative ischemic complications (PICs) after surgery. In addition, the proportion of patients receiving antiplatelet therapy (APT) in ICH patients increased significantly with age. This study aims to evaluate the impact of preoperative antiplatelet therapy on PICs in ICH patients. METHODS This is a cohort study that retrospectively analyzed the data of ICH patients who underwent surgical treatment. PICs rate was compared between patients with preoperative ATP and those without preoperative ATP. Univariate and multivariate analyses were conducted to evaluate the impact of preoperative APT on PICs. In addition, Kaplan-Meier method was used for survival analysis and the impact of PICs on patients' postoperative outcomes was evaluated. RESULTS A total of 216 patients were included in this study. There were 47 patients (21.76%) with preoperative APT; 169 patients (78.24%) without preoperative APT. The incidence of PICs in the APT group was significantly higher when compared with that in the nAPT group (36.17% vs. 20.71%, p = 0.028<0.05). Furthermore, significant differences were both observed in multivariate analysis (p = 0.035<0.05) and survival analysis (log rank χ2 = 5.415, p = 0.020<0.05). However, there was no significant difference between the outcomes of patients suffering from PICs and that of patients not suffering from PICs (p = 0.377 > 0.05). CONCLUSIONS In conclusion, preoperative APT may be a risk factor for PICs in ICH patients undergoing surgical treatment significantly.
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Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Chao Han
- Qingdao Central Hospital Group, Qingdao, P. R. China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
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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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Kulikov A, Gruenbaum SE, Quinones-Hinojosa A, Pugnaloni PP, Lubnin A, Bilotta F. Preoperative Risk Assessment Before Elective Craniotomy: Are Aspirin, Arrhythmias, Deep Venous Thromboses, and Hyperglycemia Contraindications to Surgery? World Neurosurg 2024; 186:68-77. [PMID: 38479642 DOI: 10.1016/j.wneu.2024.03.018] [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: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/18/2024]
Abstract
OBJECTIVE Perioperative risk assessment and stratification before craniotomy is necessary to identify and optimize modifiable risk factors. Due to the high costs of diagnostic testing and concerns for delaying surgery, some have questioned whether and when surgery delays are warranted and supported by the current body of literature. The objective of this scoping review was to evaluate the available evidence on the prognostic value of preoperative risk assessment before anesthesia for elective craniotomy. METHODS In this scoping review, we reviewed 156 papers that assess preoperative risk assessment before elective craniotomy, of which 27 papers were included in the final analysis. RESULTS There is little high-quality evidence to suggest significant risk reduction when 4 common preexisting abnormalities are present: preoperative chronic aspirin therapy, cardiac arrhythmias, deep vein thrombosis, or hyperglycemia. CONCLUSIONS The risk of delaying craniotomy should ultimately be weighed against the perceived risks associated the patient's comorbid conditions and should be considered on an individualized basis.
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Affiliation(s)
- Alexander Kulikov
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Shaun E Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, Jacksonville, Florida.
| | | | - Pier Paolo Pugnaloni
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrey Lubnin
- Department of Anesthesiology, Burdenko National Medical Research Center of Neurosurgery, Moscow, Russia
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Sapienza University of Rome, Rome, Italy
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Ginder CR, Suero-Abreu GA, Ghumman SS, Bergmark BA, Arnaout O, Giugliano RP. Emergent Coronary Thrombectomy for Acute Myocardial Infarction Immediately Following Craniotomy with Tumor Resection. Cardiol Ther 2024; 13:443-452. [PMID: 38536649 PMCID: PMC11093953 DOI: 10.1007/s40119-024-00356-7] [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: 10/28/2023] [Accepted: 01/17/2024] [Indexed: 05/15/2024] Open
Abstract
The management of perioperative acute myocardial infarction (AMI) following oncologic neurosurgery requires balancing competing risks of myocardial ischemia and postoperative bleeding. There are limited human data to establish the safest timing of antiplatelet or anticoagulation therapy following neurosurgical procedures. For patients with malignancy experiencing AMI in the acute postoperative period, staged percutaneous coronary intervention (PCI) with upfront coronary aspiration thrombectomy followed by delayed completion PCI may offer an opportunity for myocardial salvage while minimizing postoperative bleeding risks. CYP2C19 genotyping and platelet aggregation studies can help confirm adequate platelet inhibition once antiplatelet therapy is resumed.
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Affiliation(s)
- Curtis R Ginder
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Giselle A Suero-Abreu
- Division of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Brian A Bergmark
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Omar Arnaout
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Giugliano
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Hale BTM, Suite 7022, 60 Fenwood Road, Boston, MA, 02115, USA.
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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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Zian A, Overdevest GM, Schutte PJ, Klok FA, Steyerberg EW, Moojen WA, van der Gaag NA. Aspin: neurosurgical aspirin intervention prognostic study - perioperative continuation versus discontinuation of aspirin in lumbar spinal surgery, a randomized controlled, noninferiority trial. Trials 2024; 25:156. [PMID: 38424535 PMCID: PMC10905870 DOI: 10.1186/s13063-024-07945-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
RATIONALE Aspirin is typically discontinued in cranial and spinal surgery because of the increased risk of hemorrhagic complications, but comes together with the risk of resulting in an increase of cardiac and neurologic thrombotic perioperative events. OBJECTIVE The aim of this study is to investigate the non-inferiority of perioperative continuation of aspirin patients undergoing low complex lumbar spinal surgery, compared with the current policy of perioperative discontinuation of aspirin. STUDY DESIGN A randomized controlled trial with two parallel groups of 277 cases (554 in total). STUDY POPULATION Patients undergoing low complex lumbar spinal surgery and using aspirin. All patients are aged >18 years. INTERVENTION Peri-operative continuation of aspirin. STUDY OUTCOMES Primary study outcome: composite of the following bleeding complications: Neurological deterioration as a result of hemorrhage in the surgical area with cauda and/or nerve root compression. Post-surgical anemia with hemoglobin level lower than 5 mmol/l, requiring transfusion. Subcutaneous hematoma leading to wound leakage and pain higher than NRS=7. Major and/or minor hemorrhage in any other body system according to the definition of the International Society on Thrombosis and Haemostasis bleeding scale. Secondary study outcomes: Each of the individual components of the primary outcome Absolute mean difference in operative blood loss between the study arms Thrombo-embolic-related complications: Myocardial infarction Venous thromboembolism Stroke Arterial thromboembolism FURTHER STUDY OUTCOMES: Anticoagulant treatment satisfaction by the Anti-Clot Treatment Scale (ACTS) and general health by the Patient-Reported Outcomes Measurement Information System (PROMIS Global-10) in the pre- and postoperative phase. NATURE AND EXTENT OF THE BURDEN AND RISKS ASSOCIATED WITH PARTICIPATION, BENEFIT, AND GROUP RELATEDNESS: Participation in this study imposes no additional risk to patients. Currently, there is no consensus on whether or not aspirin should be discontinued before cranial or spinal surgery. Currently, aspirin is typically discontinued in cranial and spinal surgery, because of a potential increased risk of hemorrhagic complication. An argument not based on a clinical trial. However, this policy might delay surgical procedures or carry the risk of resulting in an increase in cardiac and neurologic thrombotic perioperative events. It is unclear if the possibility of an increase in hemorrhage-related complications outweighs the risk of an increase in cardiac and neurologic thrombotic perioperative events. Furthermore, the Data Safety Monitoring Board (DSMB) will be asked for safety analysis by monitoring the study. There are no further disadvantages to participating in this study. Outcome measurements are recorded during admission and regular outpatient visits, and thus, do not require additional visits to the hospital.
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Affiliation(s)
- Ahmed Zian
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands.
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands.
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands.
| | - Gijsbert M Overdevest
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Pieter J Schutte
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Vascular Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Ewout W Steyerberg
- Department of Clinical Biostatistics and Medical Decision Making, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Wouter A Moojen
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Leiden University Medical center (LUMC), Leiden, The Netherlands
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, The Netherlands
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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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10
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Bazzi R, Sharp V, Hecht J. Effect of Antiplatelet and Anticoagulant Agents on Outcomes Following Emergent Surgery for Traumatic Brain Injuries. Am Surg 2023; 89:5397-5406. [PMID: 36786276 DOI: 10.1177/00031348231157412] [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] [Indexed: 02/15/2023]
Abstract
PURPOSE Traumatic brain injury (TBI) is the largest cause of death from injury in the United States. This study utilized the Michigan Trauma Quality Improvement Program (MTQIP) database to determine the effect that antiplatelets and anticoagulants (AP/AC) have on outcomes following emergent surgery for TBI patients. BASIC PROCEDURES Patients were included with age ≥18 years, maximum head/neck abbreviated injury score (AIS) ≥2, and underwent a neurosurgical procedure within 24 hours. Patients were excluded if they had an AIS ≥3 in other body region or no signs of life at initial evaluation. MAIN FINDINGS Within the 1,932 patients analyzed, 139 (8.74%) were in the warfarin with or without (+/-) aspirin cohort, 101 (6.35%) in the direct oral anticoagulants (DOAC) +/- aspirin cohort, 169 (10.62%) in the clopidogrel +/- aspirin cohort, and 1,182 (74.29%) in the no AP/AC cohort (control group). After controlling for demographic and clinical characteristics, no significant difference in mortality rates was observed in the treatment groups (P > 0.05). However, our subgroup analysis did reveal a significantly higher mortality rate within the warfarin and aspirin subgroup when compared to the control group (odds ratio [OR], 2.368; confidence interval [CI], 1.306-4.294, P = 0.005). With regards to hospital complications, there was a significant increase in this outcome within the DOAC +/- aspirin (OR, 1.825; CI, 1.143-2.915, P = 0.012) and clopidogrel +/- aspirin (OR, 1.82; CI, 1.244-2.663, P=0.002) groups. CONCLUSION Patients on AP/AC who experience a TBI requiring an emergent operation do not have an increased risk of mortality compared to patients not on AP/AC.
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Affiliation(s)
- Rola Bazzi
- Inpatient Pharmacy, Trinity Health Ann Arbor, Ypsilant, MI, USA
| | - Victoria Sharp
- Department of Surgery, Trinity Health Ann Arbor, Ypsilant, MI, USA
| | - Jason Hecht
- Inpatient Pharmacy, Trinity Health Ann Arbor, Ypsilant, MI, USA
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11
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Mahendran S, Thiagalingam A, Hillis G, Halliwell R, Pleass HC, Chow CK. Cardiovascular risk management in the peri-operative setting. Med J Aust 2023. [PMID: 37302136 DOI: 10.5694/mja2.51988] [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: 11/29/2022] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 06/13/2023]
Abstract
Peri-operative cardiovascular events occur in up to 3% of patients undergoing non-cardiac surgery. Accurate cardiovascular risk assessment is important in the peri-operative setting, as it allows informed and shared decisions regarding the appropriateness of proceeding with surgery, guides surgical and anaesthetic approaches, and may influence the use of preventive medications and post-operative cardiac monitoring. Quantitative risk assessment may also inform a reconsideration of choosing a more limited lower risk type of surgery, or conservative management. Pre-operative cardiovascular risk assessment starts with clinical assessment and should include an estimate of functional capacity. Specialised cardiac investigations are rarely indicated specifically to assess pre-operative cardiovascular risk. The decision regarding cardiac investigations is influenced by the nature, extent and urgency of surgery. The strategy of performing pre-operative revascularisation to improve post-operative outcomes is not evidence-based and recent international guidelines recommend against this.
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Affiliation(s)
| | | | | | | | - Henry Cc Pleass
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW
| | - Clara K Chow
- Westmead Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
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Hjelmdal C, Draegert C, Vester-Andersen M, Kowark A, Coburn M, Rasmussen LS, Lundstrøm LH, Steinmetz J. Intra-operative blood transfusion in elderly patients on antithrombotic therapy. Acta Anaesthesiol Scand 2023; 67:412-421. [PMID: 36636858 DOI: 10.1111/aas.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/10/2022] [Accepted: 01/06/2023] [Indexed: 01/14/2023]
Abstract
BACKGROUND Many elderly patients are receiving antithrombotics, which may increase intra-operative blood loss. We aimed to assess whether chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in patients at least 80 years of age undergoing elective procedures. METHODS We performed a secondary analysis of the prospective, observational European multicentre study entitled POSE (peri-interventional outcome study in the elderly) including 9497 surgical patients aged 80 years and older in 177 centres from October 2017 to December 2018. In this secondary analysis we included POSE patients who underwent elective procedures and with available data on chronic antithrombotic therapy. The primary outcome was intra-operative transfusion of packed red blood cells and results were analysed using multiple logistic regression model. We adjusted for the following predetermined explanatory variables: Age, sex, body mass index, American Society of Anaesthesiologists Physical Status Classification System, baseline haemoglobin concentration, disseminated cancer, and type and severity of surgery. RESULTS A total of 7174 patients were included of whom 4073 (56.8%) were on antithrombotic therapy. Among patients on antithrombotic therapy 191 (4.7%) received intra-operative blood transfusion compared with 98 (3.2%) of patients not on chronic antithrombotic therapy (crude odds ratio: 1.51, 95% CI 1.18-1.94). Following multiple logistic regression analysis, the adjusted odds ratio was 0.98; 0.73-1.32. We found that chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in elderly patients undergoing elective procedures in an unadjusted analysis, but not in a multivariate adjusted model.
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Affiliation(s)
- Caroline Hjelmdal
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christina Draegert
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Department of Anesthesiology, Copenhagen University Hospital, Herlev-Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Ana Kowark
- Department of Anaesthesia, University Hospital RWTH, Aachen, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Mark Coburn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Lars H Lundstrøm
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Department of Anaesthesia, Nordsjaellands Hospital, Hillerød, Denmark
| | - Jacob Steinmetz
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
- Danish Air Ambulance, Aarhus, Denmark
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13
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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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Westfall KM, Ramcharan RN, Anderson HL. Myocardial infarction after craniotomy for asymptomatic meningioma. BMJ Case Rep 2022; 15:e252256. [PMID: 36581354 PMCID: PMC9806024 DOI: 10.1136/bcr-2022-252256] [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] [Indexed: 12/31/2022] Open
Abstract
A man in his 40s with a history of coronary artery disease previously treated with a drug-eluting stent presented for elective craniotomy and resection of an asymptomatic but enlarging meningioma. During his craniotomy, he received desmopressin and tranexamic acid for surgical bleeding. Postoperatively, the patient developed chest pain and was found to have an ST-elevation myocardial infarction (MI). Because of the patient's recent neurosurgery, standard post-MI care was contraindicated and he was instead managed symptomatically in the intensive care unit. Echocardiogram on postoperative day 1 demonstrated no regional wall motion abnormalities and an ejection fraction of 60%. His presentation was consistent with thrombosis of his diagonal stent. He was transferred out of the intensive care unit on postoperative day 1 and discharged home on postoperative day 3.
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15
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Ziesenitz VC, Welzel T, van Dyk M, Saur P, Gorenflo M, van den Anker JN. Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years. Paediatr Drugs 2022; 24:603-655. [PMID: 36053397 PMCID: PMC9592650 DOI: 10.1007/s40272-022-00514-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.
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Affiliation(s)
- Victoria C Ziesenitz
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland.
| | - Tatjana Welzel
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Pediatric Rheumatology and Autoinflammatory Reference Center, University Hospital Tuebingen, Tuebingen, Germany
| | - Madelé van Dyk
- Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Patrick Saur
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Matthias Gorenflo
- Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
| | - Johannes N van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
- Division of Clinical Pharmacology, Children's National Hospital, Washington DC, USA
- Intensive Care and Department of Pediatric Surgery, Sophia Children's Hospital, Rotterdam, The Netherlands
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16
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Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis. Mayo Clin Proc Innov Qual Outcomes 2022; 6:564-573. [PMID: 36304523 PMCID: PMC9594114 DOI: 10.1016/j.mayocpiqo.2022.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures. METHODS This systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database's inception to July 16, 2020. Meta-analyses were conducted when possible. RESULTS In patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE). CONCLUSION This systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.
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Key Words
- ACCP/CHEST, American College of Chest Physicians
- ASA, acetylsalicylic acid
- ATE, arterial thromboembolism
- CABG, coronary artery bypass graft
- COE, certainty of evidence
- CV, cardiovascular
- DES, drug-eluting stent
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- PE, pulmonary embolism
- PICO, patients–interventions–comparators–outcomes
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RCT, randomized clinical trial
- RR, relative risk
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17
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Yang J, Liu Q, Mo S, Wang K, Li M, Wu J, Jiang P, Yang S, Guo R, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. The Effect of Preoperative Antiplatelet Therapy on Early Postoperative Rehemorrhage and Outcomes in Patients With Spontaneous Intracranial Hematoma. Front Aging Neurosci 2021; 13:681998. [PMID: 34276341 PMCID: PMC8283695 DOI: 10.3389/fnagi.2021.681998] [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: 03/17/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose The effect of antiplatelet therapy (APT) on early postoperative rehemorrhage and outcomes of patients with spontaneous intracerebral hemorrhage (ICH) is still unclear. This study is to evaluate the effect of preoperative APT on early postoperative rehemorrhage and outcomes in ICH patients. Methods This was a multicenter cohort study. ICH patients undergoing surgery were divided into APT group and no antiplatelet therapy (nAPT) group according to whether patients received APT or not. Chi-square test, t-test, and Mann–Whitney U test were used to compare the differences in variables, postoperative rehematoma, and outcomes between groups. Multivariate logistics regression analysis was used to correct for confounding variables, which were different in group comparison. Results One hundred fifty ICH patients undergoing surgical treatment were consecutively included in this study. Thirty five (23.33%) people were included in the APT group, while 115 (76.67%) people were included in the nAPT group. The incidence of early postoperative rehemorrhage in the APT group was significantly higher than that in the nAPT group (25.7% VS 10.4%, p = 0.047 < 0.05). After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT had no significant effect on early postoperative rehemorrhage (p = 0.067). There was no statistical difference between the two groups in early poorer outcomes (p = 0.222) at 14 days after surgery. After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT also had no significant effect on early poorer modified Rankin Scale (mRS) (p = 0.072). Conclusion In conclusion, preoperative APT appears to be safe and have no significant effect on early postoperative rehematoma and outcomes in ICH patients.
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Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Maogui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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18
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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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19
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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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20
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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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Raghavan A, Smith G, Onyewadume L, Peck MR, Herring E, Pace J, Rogers M, Momotaz H, Hoffer SA, Hu Y, Liu H, Tatsuoka C, Sajatovic M, Sloan AE. Morbidity and Mortality After Burr Hole Craniostomy Versus Craniotomy for Chronic Subdural Hematoma Evacuation: A Single-Center Experience. World Neurosurg 2020; 134:e196-e203. [DOI: 10.1016/j.wneu.2019.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 12/21/2022]
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Sebök M, Keller E, van Niftrik CHB, Regli L, Germans MR. Management of Aneurysmal Subarachnoid Hemorrhage Patients with Antiplatelet Use Before the Initial Hemorrhage: An International Survey. World Neurosurg 2018; 120:e408-e413. [DOI: 10.1016/j.wneu.2018.08.094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 11/25/2022]
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Skardelly M, Mönch L, Roder C, Hockel K, Tatagiba MS, Ebner FH. Survey of the management of perioperative bridging of anticoagulation and antiplatelet therapy in neurosurgery. Acta Neurochir (Wien) 2018; 160:2077-2085. [PMID: 30238395 DOI: 10.1007/s00701-018-3679-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND A growing number of patients on anticoagulation or antiplatelet therapy (APT) are planned for elective surgery. The management of perioperative anticoagulation and APT is challenging because it must balance the risk of thromboembolism and bleeding, and specific recommendations for the management of bridging in neurosurgical patients are lacking. We surveyed German neurosurgical centers about their management of perioperative bridging of anticoagulation and APT to provide an overview of the current bridging policy. METHOD From April to August 2016, all German neurosurgical departments were invited to participate in the survey. We used SurveyMonkey to compose ten questions and to conduct the survey, and we defined three different approaches for the perioperative management of patients on a preexisting medication: medication will be discontinued (A) with perioperative "bridging" and (B) without perioperative bridging, or (C) medication will be continued perioperatively. RESULTS Out of 141 respondents, 84 (60%) partially and 77 (55%) fully completed the questionnaire. No defined policy for the perioperative management of anticoagulation and APT was established in 60.7% (51/84) of participating centers. The perioperative management of anticoagulation and APT varied widely among different centers in all items of the questionnaire; for example, in the group of patients at high risk for thromboembolism, acetylsalicylic acid was discontinued in 22%, bridged in 35%, and continued in 35% of centers. CONCLUSIONS There is significant uncertainty regarding the management of perioperative bridging of anticoagulation and APT in neurosurgery because of a lack of prospective and limited retrospective data.
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Affiliation(s)
- Marco Skardelly
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology and Neurosurgery, University Hospital Tuebingen, Eberhard Karls University of Tübingen, Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
- Neuro-Oncology Center, Comprehensive Cancer Center Tübingen, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Lisa Mönch
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Constantin Roder
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology and Neurosurgery, University Hospital Tuebingen, Eberhard Karls University of Tübingen, Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Neuro-Oncology Center, Comprehensive Cancer Center Tübingen, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Konstantin Hockel
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Soares Tatagiba
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology and Neurosurgery, University Hospital Tuebingen, Eberhard Karls University of Tübingen, Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Neuro-Oncology Center, Comprehensive Cancer Center Tübingen, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Florian H Ebner
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology and Neurosurgery, University Hospital Tuebingen, Eberhard Karls University of Tübingen, Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Neuro-Oncology Center, Comprehensive Cancer Center Tübingen, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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Lomivorotov VV, Efremov SM, Abubakirov MN, Belletti A, Karaskov AM. Perioperative Management of Cardiovascular Medications. J Cardiothorac Vasc Anesth 2018; 32:2289-2302. [DOI: 10.1053/j.jvca.2018.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Indexed: 12/28/2022]
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Sierra P, Gómez-Luque A, Llau JV, Ferrandis R, Cassinello C, Hidalgo F. 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. ACTA ACUST UNITED AC 2018; 66:18-36. [PMID: 30166124 DOI: 10.1016/j.redar.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022]
Affiliation(s)
- P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España.
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Dr. Peset, Universitat de València, Valencia, España
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hopital Clínic i Universitari La Fe, Universitat de València, Valencia, España
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, España
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Goldhammer JE, Herman CR, Sun JZ. Perioperative Aspirin in Cardiac and Noncardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1060-1070. [DOI: 10.1053/j.jvca.2016.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Indexed: 01/09/2023]
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Han H, Koh EJ, Choi H, Kim BC, Yang SY, Cho KT. The Effect of Preoperative Antiplatelet Therapy on Hemorrhagic Complications after Decompressive Craniectomy in Patients with Traumatic Brain Injury. Korean J Neurotrauma 2016; 12:61-66. [PMID: 27857909 PMCID: PMC5110920 DOI: 10.13004/kjnt.2016.12.2.61] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/30/2016] [Accepted: 09/09/2016] [Indexed: 11/30/2022] Open
Abstract
Objective Traditionally, it is generally recommended that antiplatelet agent should be discontinued before surgery. However, decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) is performed emergently in most cases. Therefore, DC cannot be delayed to the time when the effect of antiplatelet agent on bleeding tendency dissipates. In this study, we evaluated the effect of preinjury antiplatelet therapy on hemorrhagic complications after emergent DC in patients with TBI. Methods We retrospectively investigated patients with TBI who underwent emergent DC between 2006 and 2015. The patients were separated into two groups according to the use of preinjury antiplatelet agent: group 1 (patients taking antiplatelet agent) and group 2 (patients not taking antiplatelet agent). The rate of hemorrhagic complications (postoperative epidural or subdural hemorrhage, newly developed, or progression of preexisting contusion or intracerebral hemorrhage within the field of DC) and the rate of reoperation within 7 days after DC were compared between two groups. Results During the study period, DC was performed in 90 patients. Of them, 19 patients were taking antiplatelet agent before TBI. The rate of hemorrhagic complications was 52.6% (10/19) in group 1 and 46.5% (33/71) in group 2 (p=0.633). The rate of reoperation was 36.8% (7/19) in group 1 and 36.6% (26/71) in group 2 (p=0.986). No statistical difference was found between two groups. Conclusion Preinjury antiplatelet therapy did not influence the rate of hemorrhagic complications and reoperation after DC. Emergent DC in patients with TBI should not be delayed because of preinjury antiplatelet therapy.
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Affiliation(s)
- Hokyun Han
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Eun Jung Koh
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hyunho Choi
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Byong-Cheol Kim
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Seung Yeob Yang
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Keun-Tae Cho
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
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