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Perioperative Management of Patients on Chronic Aspirin Therapy for Elective Brain Surgery: A Delphi Study
Shaun E Gruenbaum1, Alexander Kulikov2, Ilana Logvinov1
1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic-Florida, FL.
Insights
Managing chronic aspirin therapy before brain surgery involves balancing bleeding and clotting risks. Experts recommend stopping aspirin 5-7 days before high-risk bleeding procedures but continuing it for high-thrombotic-risk patients.
Area of Science:
- Neurosurgery
- Anesthesiology
- Cardiology
Background:
- Perioperative aspirin management in elective brain surgery presents a dilemma between bleeding and thromboembolic risks.
- Discontinuing aspirin reduces bleeding but may increase thrombotic complications, especially in high-cardiovascular-risk patients.
Purpose of the Study:
- To develop consensus-based guidelines for managing chronic aspirin therapy in patients undergoing elective neurosurgery.
- To address the clinical challenges posed by balancing bleeding and thrombotic risks.
Main Methods:
- A 2-round Delphi survey involving 42 international anesthesiologists and neurosurgeons.
- Assessment of risks, benefits, cessation/resumption timing, and platelet function testing utility.
- Consensus defined as ≥80% agreement in round 2.
Main Results:
- Consensus reached: continuing aspirin increases bleeding risk (84%), recommend cessation 5-7 days prior (87%).
- Strong agreement (97%) to continue low-dose aspirin in high-thrombotic-risk patients.
- Debate persists for low-thrombotic-risk patients (65% agreement for continuation); no consensus on routine platelet function testing.
Conclusions:
- Experience-based recommendations for perioperative aspirin management in neurosurgical patients.
- Strong support for continuing aspirin in high-thrombotic-risk patients; cessation 5-7 days before high-bleeding-risk surgery.
- Individualized management needed for low-risk patients; further research on platelet function testing is recommended.
Background:
The perioperative management of chronic aspirin therapy in patients undergoing elective brain surgery is challenging due to the risk of bleeding and thromboembolic events. Although aspirin discontinuation reduces the bleeding risk, it can increase thrombotic complications, particularly in patients at high risk of cardiovascular complications. This Delphi study aimed to develop consensus-based guidelines to address these clinical challenges.
Methods:
A 2-round Delphi survey was conducted among an international panel of 42 experienced anesthesiologists and neurosurgeons. Participants assessed the risks and benefits of perioperative aspirin management, including bleeding risk, thrombotic risk, timing of cessation and resumption, and the utility of platelet function testing. Consensus was defined as ≥80% agreement in round 2.
Results:
Round 1 highlighted significant variability in practice patterns. In round 2, consensus was reached on several key areas. Most experts (84%) agreed that continuing aspirin increases perioperative bleeding risk in high-risk procedures, with 87% recommending discontinuing aspirin 5 to 7 days before surgery. Nearly all experts (97%) supported continuing low-dose aspirin in high-thrombotic-risk patients. Conversely, for low-thrombotic-risk patients, only 65% agreed on aspirin continuation, reflecting an ongoing debate. No consensus was reached regarding routine platelet function testing.
Conclusions:
This Delphi study provides experience-based recommendations for managing chronic aspirin therapy in neurosurgical patients. The panel strongly supports aspirin continuation in high-thrombotic-risk patients, with cessation 5 to 7 days before high-bleeding-risk surgeries. Individualized management is advised for low-bleeding-risk procedures and low-thrombotic-risk patients. Future research should further clarify aspirin management in these groups and explore the role of platelet function testing in neurosurgical settings.
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