OBJECTIVEIn 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.METHODSThe 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.RESULTSA 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.CONCLUSIONSIn 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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BACKGROUND Determining if paraclinoid aneurysms are intradural or extradural is critical for surgical planning. OBJECTIVE To create an easily reproducible diagnostic method based on bony anatomy that precisely locates the distal dural ring (DDR) to determine the position of paraclinoid aneurysms as intradural, transitional, or extradural. METHODS Bilateral anatomic dissections of 10 cadaveric heads (20 sides) were performed to evaluate DDR anatomy. We observed a plane that reflects the position of the DDR passes through 4 bony landmarks: 1) The anterior clinoid-internal carotid artery intersection, 2) the optic strut, 3) the optico-carotid elevation, and 4) the base of the posterior clinoid process. This landmark-based plane can thus define the location of the DDR using 3-dimensional computed tomography angiography (CTA). This was confirmed in 27 surgical patients with intradural/transitional aneurysms and 7 patients with extradural aneurysms confirmed with magnetic resonance imaging (MRI). The DDR plane method easily classified aneurysm locations as intradural (above the DDR plane), extradural (below the DDR plane), or transitional (the DDR plane crosses the aneurysm). The aneurysm's location was subsequently confirmed intraoperatively or with MRI. RESULTS The DDR plane method determined if paraclinoid aneurysms were intradural, transitional, or extradural in all 34 cases examined. The visibility of the anatomic features that define the DDR plane was also verified in 82% to 89% of CTA images from 100 patients. CONCLUSION The DDR plane method provides a useful diagnostic tool to evaluate the position of the DDR and determine the anatomic location of paraclinoid aneurysms.

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