Effect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study

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  • Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

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.

ABBREVIATIONS ASA = acetylsalicylic acid; CI = confidence interval; EOR = extent of resection; MI = myocardial infarction; OR = odds ratio.

Contributor Notes

Correspondence Mustafa K. Baskaya: Department of Neurological Surgery, University of Wisconsin, Madison, WI. baskaya@neurosurgery.wisc.edu

INCLUDE WHEN CITING Published online April 5, 2019; DOI: 10.3171/2018.12.JNS182483.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Akhavan-Sigari R, Rohde V, Abili M: Continuation of medically necessary platelet aggregation inhibitors—acetylsalicylic acid and clopidogrel—during surgery for spinal degenerative disorders: results in 100 patients. Surg Neurol Int 5 (Suppl 7):S376S379, 2014

    • Search Google Scholar
    • Export Citation
  • 2

    Armstrong MJ, Schneck MJ, Biller J: Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients. Neurol Clin 24:607630, 2006

    • Search Google Scholar
    • Export Citation
  • 3

    Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R, : Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 373:18491860, 2009

    • Search Google Scholar
    • Export Citation
  • 4

    Banerjee S, Angiolillo DJ, Boden WE, Murphy JG, Khalili H, Hasan AA, : Use of antiplatelet therapy/DAPT for post-PCI patients undergoing noncardiac surgery. J Am Coll Cardiol 69:18611870, 2017

    • Search Google Scholar
    • Export Citation
  • 5

    Birkeland P, Lauritsen J, Poulsen FR: Aspirin is associated with an increased risk of subdural hematoma in normal-pressure hydrocephalus patients following shunt implantation. J Neurosurg 123:423426, 2015

    • Search Google Scholar
    • Export Citation
  • 6

    Bruder M, Won SY, Wagner M, Brawanski N, Dinc N, Kashefiolasl S, : Continuous acetylsalicylic acid treatment does not influence bleeding pattern or outcome of aneurysmal subarachnoid hemorrhage: a matched-pair analysis. World Neurosurg 113:e122e128, 2018

    • Search Google Scholar
    • Export Citation
  • 7

    Burger W, Chemnitius JM, Kneissl GD, Rücker G: Low-dose aspirin for secondary cardiovascular prevention—cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation—review and meta-analysis. J Intern Med 257:399414, 2005

    • Search Google Scholar
    • Export Citation
  • 8

    Cheng A, Poon MTC, Demetriades AK: Aspirin therapy discontinuation and intraoperative blood loss in spinal surgery: a systematic review. Neurosurg Rev 41:10291036, 2018

    • Search Google Scholar
    • Export Citation
  • 9

    Darvish-Kazem S, Douketis JD: Perioperative management of patients having noncardiac surgery who are receiving anticoagulant or antiplatelet therapy: an evidence-based but practical approach. Semin Thromb Hemost 38:652660, 2012

    • Search Google Scholar
    • Export Citation
  • 10

    Dasenbrock HH, Yan SC, Gross BA, Guttieres D, Gormley WB, Frerichs KU, : The impact of aspirin and anticoagulant usage on outcomes after aneurysmal subarachnoid hemorrhage: a Nationwide Inpatient Sample analysis. J Neurosurg 126:537547, 2017

    • Search Google Scholar
    • Export Citation
  • 11

    Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, Alonso-Coello P, Kurz A, : Aspirin in patients undergoing noncardiac surgery. N Engl J Med 370:14941503, 2014

    • Search Google Scholar
    • Export Citation
  • 12

    Duceppe E, Mrkobrada M, Thomas S, Devereaux PJ: Role of aspirin for prevention and treatment of perioperative cardiovascular events. J Thromb Haemost 13 (Suppl 1):S297S303, 2015

    • Search Google Scholar
    • Export Citation
  • 13

    Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, : 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 130:22152245, 2014

    • Search Google Scholar
    • Export Citation
  • 14

    Gerstein NS, Carey MC, Cigarroa JE, Schulman PM: Perioperative aspirin management after POISE-2: some answers, but questions remain. Anesth Analg 120:570575, 2015

    • Search Google Scholar
    • Export Citation
  • 15

    Gerstein NS, Schulman PM, Gerstein WH, Petersen TR, Tawil I: Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome. Ann Surg 255:811819, 2012

    • Search Google Scholar
    • Export Citation
  • 16

    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 17:19391946, 2017

    • Search Google Scholar
    • Export Citation
  • 17

    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 12:6166, 2016

    • Search Google Scholar
    • Export Citation
  • 18

    Kamenova M, Nevzati E, Lutz K, Dolp A, Fandino J, Mariani L, : Burr-hole drainage for chronic subdural hematoma under low-dose acetylsalicylic acid: a comparative risk analysis study. World Neurosurg 100:594600, 2017

    • Search Google Scholar
    • Export Citation
  • 19

    Kiberd MB, Hall RI: Aspirin in the perioperative period: a review of the recent literature. Curr Opin Anaesthesiol 28:349355, 2015

  • 20

    Korinth MC: Low-dose aspirin before intracranial surgery—results of a survey among neurosurgeons in Germany. Acta Neurochir (Wien) 148:11891196, 2006

    • Search Google Scholar
    • Export Citation
  • 21

    Korinth MC, Gilsbach JM, Weinzierl MR: Low-dose aspirin before spinal surgery: results of a survey among neurosurgeons in Germany. Eur Spine J 16:365372, 2007

    • Search Google Scholar
    • Export Citation
  • 22

    Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, : 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 35:23832431, 2014

    • Search Google Scholar
    • Export Citation
  • 23

    Lee AT, Gagnidze A, Pan SR, Sookplung P, Nair B, Newman SF, : Preoperative low-dose aspirin exposure and outcomes after emergency neurosurgery for traumatic intracranial hemorrhage in elderly patients. Anesth Analg 125:514520, 2017

    • Search Google Scholar
    • Export Citation
  • 24

    Levy M, Heels-Ansdell D, Hiralal R, Bhandari M, Guyatt G, Yusuf S, : Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis. Anesthesiology 114:796806, 2011

    • Search Google Scholar
    • Export Citation
  • 25

    McCunniff PT, Young ES, Ahmadinia K, Kusin DJ, Ahn UM, Ahn NU: Chronic antiplatelet use associated with increased blood loss in lumbar spinal surgery despite adherence to protocols. Orthopedics 39:e695e700, 2016

    • Search Google Scholar
    • Export Citation
  • 26

    Ogawa Y, Tominaga T: Sellar and parasellar tumor removal without discontinuing antithrombotic therapy. J Neurosurg 123:794798, 2015

  • 27

    Oprea AD, Popescu WM: Perioperative management of antiplatelet therapy. Br J Anaesth 111 (Suppl 1):i3i17, 2013

  • 28

    Park HJ, Kwon KY, Woo JH: Comparison of blood loss according to use of aspirin in lumbar fusion patients. Eur Spine J 23:17771782, 2014

    • Search Google Scholar
    • Export Citation
  • 29

    Rahman M, Donnangelo LL, Neal D, Mogali K, Decker M, Ahmed MM: Effects of perioperative acetyl salicylic acid on clinical outcomes in patients undergoing craniotomy for brain tumor. World Neurosurg 84:4147, 2015

    • Search Google Scholar
    • Export Citation
  • 30

    Soni A: Aspirin Use Among the Adult U.S. Noninstitutionalized Population, With and Without Indicators of Heart Disease, 2005. Statistical Brief #179. Rockville, MD: Agency for Healthcare Research and Quality, 2007

    • Export Citation
  • 31

    Williams CD, Chan AT, Elman MR, Kristensen AH, Miser WF, Pignone MP, : Aspirin use among adults in the U.S.: results of a national survey. Am J Prev Med 48:501508, 2015

    • Search Google Scholar
    • Export Citation
  • 32

    Wolff G, Navarese EP, Brockmeyer M, Lin Y, Karathanos A, Kołodziejczak M, : Perioperative aspirin therapy in non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 258:5967, 2018

    • Search Google Scholar
    • Export Citation
  • 33

    World Health Organization: Prevention of Cardiovascular Disease: Guidelines for Assessment and Management of Cardiovascular Risk. Geneva: World Health Organization, 2007

    • Export Citation
  • 34

    Zhou Y, Boudreau DM, Freedman AN: Trends in the use of aspirin and nonsteroidal anti-inflammatory drugs in the general U.S. population. Pharmacoepidemiol Drug Saf 23:4350, 2014

    • Search Google Scholar
    • Export Citation

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