Aspirin use or reduced platelet activity predicts craniotomy after intracerebral hemorrhage

Craniotomy is potentially life-saving in selected patients with intracerebral hemorrhage (ICH). Aside from specific scenarios (cerebellar hemorrhage with hydrocephalus, midline shift from an accessible lesion, etc.) the indications for surgical decompression are controversial. Based on the earlier work that aspirin and reduced platelet activity are associated with larger hemorrhage size and hemorrhage growth, we tested the hypothesis that aspirin or reduced platelet activity would be associated with increased odds of craniotomy, likely through hemorrhage growth.

We prospectively identified patients with spontaneous ICH and routinely measured platelet activity on admission. Patients were prospectively tracked, and outcomes were obtained with the modified Rankin Scale (mRS).

There were 187 patients in the sample. Craniotomy (N = 32, 17%) was associated with a higher initial ICH volume (37.9 [20-63] vs. 12 [5-24] ml, P < 0.001) and location (P = 0.005). In multivariate logistic regression, after controlling for ICH volume and location, any known aspirin use (OR 3.4, 95% CI 1.1-10.4, P = 0.03), platelet activity ≤550 aspirin reaction units (OR 3.1, 95% CI 1.05-9.3, P = 0.04), or an elevated PFA-EPI closure time (OR 3.2, 95% CI 1.02-10.3, P = 0.04) were associated with increased odds of craniotomy. Craniotomy was not associated with mRS at 14 days, 28 days, or 3 months.

After correction for ICH volume and location, aspirin use or reduced platelet activity was associated with similar increased odds for craniotomy.