Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients

Lee, Alex T.; Gagnidze, Arni; Pan, Sharon R.; Sookplung, Pimwan; Nair, Bala G.; Newman, Shu Fang; Ben-Ari, Alon; Zaky, Ahmed; Cain, Kevin P.; Vavilala, Monica S.; Rozet, Irene

doi:10.1213/ane.0000000000002053

Cited by 25 publications

(23 citation statements)

References 32 publications

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“…In contrast, aspirin exposure was not associated with progression of haemorrhage on CT, clinical deterioration or mortality in traumatic ICH [289, 802]. In older patients on preoperative low-dose aspirin undergoing emergency neurosurgery for traumatic ICH, there was also no increased perioperative bleeding, length of hospital stay or in-hospital mortality, but these results should be corroborated with the higher perioperative platelet transfusion rate in patients receiving aspirin therapy [803]. A recent meta-analysis confirmed a statistical association between clopidogrel and clinical deterioration or neurosurgical intervention, but no association between aspirin use and these outcomes in TBI patients [804].…”

Section: Resultsmentioning

confidence: 99%

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The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

et al. 2019

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Background: Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods: The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reexamined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results: Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient-or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

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Section: Resultsmentioning

confidence: 99%

“…Platelet transfusion given before cranial decompressive surgery was partially effective in patients on clopidogrel [823]. In TBI patients on APA pre-treatment, platelet transfusion did not improve the neurological outcome [309, 794, 803], but was associated with increased infections and complications [794].…”

Section: Resultsmentioning

confidence: 99%

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

et al. 2019

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“…7 Studies on the management of neurosurgical patients treated with AP or AC therapy undergoing craniotomy, especially in the setting of TBI, are sparse. 6,11,20,22,25,27 The aim of this study was to analyze hemorrhagic complications in patients treated with AP or AC therapy undergoing craniotomy due to TBI.…”

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confidence: 99%

Effect of preoperative antiplatelet or anticoagulation therapy on hemorrhagic complications in patients with traumatic brain injury undergoing craniotomy or craniectomy

Greuter

Ullmann

Mariani

et al. 2019

Neurosurgical Focus

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OBJECTIVETraumatic 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.METHODSPostoperative 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.RESULTSOf 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.CONCLUSIONSPatients 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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“…Hemorrhage can result in increased need for transfusion of blood products, and an increased rate of reoperation (LOE 6, Fair) . Human patient groups at higher risk for hemorrhage may include those undergoing intracranial surgery, cardiac surgery, and transurethral prostatectomy (LOE 6, Fair) …”

Section: Pico Question: Discontinuation Antiplatelet Agents Before Sumentioning

confidence: 99%

Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 5—Discontinuation of anticoagulant therapy in small animals

Brainard

Buriko

Good

et al. 2019

J Vet Emergen Crit Care

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Objectives: To systematically evaluate the evidence supporting the timing and mechanisms of permanent or temporary discontinuation of antiplatelet or anticoagulant medications in small animals Design: Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality (poor, fair, or good), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. Settings: Academic and referral veterinary medical centers.Results: Databases searched included Medline via PubMed and CAB abstracts. Two specific courses of inquiry were pursued, one focused on appropriate approaches to use for small animal patients receiving antiplatelet or anticoagulant drugs and requiring temporary discontinuation of this therapy for the purposes of invasive procedures (eg, surgery), and the other aimed at decision-making for the complete discontinuation of anticoagulant medications. In addition, the most appropriate methodology for discontinuation of heparins was addressed. Conclusions:To better define specific patient groups, a risk stratification characterization was developed. It is recommended to continue anticoagulant therapy through invasive procedures in patients at high risk for thrombosis that are receiving anticoagulant therapy, while consideration for discontinuation in patients with low to moderate risk of thrombosis is reasonable. In patients with thrombosis in whom the underlying cause for thrombosis has resolved, indefinite treatment with anticoagulant medication is not recommended. If the underlying cause is unknown or untreatable, anticoagulant medication should be continued indefinitely. Unfractionated heparin therapy should be slowly tapered rather than discontinued abruptly. K E Y W O R D Saspirin, clopidogrel, CURATIVE, heparin, rivaroxaban 88

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Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients

Abstract: In patients age ≥65 years undergoing emergency neurosurgery for traumatic intracranial hemorrhage, preoperative low-dose aspirin treatment was not associated with increased perioperative bleeding, hospital lengths of stay, or in-hospital mortality.

Cited by 25 publications

References 32 publications

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

Effect of preoperative antiplatelet or anticoagulation therapy on hemorrhagic complications in patients with traumatic brain injury undergoing craniotomy or craniectomy

Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 5—Discontinuation of anticoagulant therapy in small animals

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