Perioperative aspirin discontinuation prior to burr-hole drainage for chronic subdural hematoma: A European multicenter retrospective cohort study.
Continuing aspirin therapy before burr-hole drainage for chronic subdural hematoma may increase the risk of early postoperative hemorrhagic events.
Where it sits
this study against the rest of the desmopressin corpusSummary and findings
This study evaluated the impact of perioperative aspirin discontinuation on postoperative outcomes in patients undergoing burr-hole drainage for chronic subdural hematoma. A total of 140 patients were analyzed, categorized into continuation, short-pause, and long-pause groups. The findings indicated a higher incidence of acute postoperative hemorrhagic events in the continuation group compared to those who discontinued aspirin.
Abstract
<h4>Background</h4>Chronic subdural hematoma (cSDH) frequently affects elderly patients receiving low-dose aspirin, yet the optimal perioperative management of aspirin before burr-hole drainage remains uncertain. We assessed whether the timing of aspirin discontinuation influences early postoperative hemorrhagic and thromboembolic events, functional outcome, recurrence, and length of stay (LOS).<h4>Methods</h4>Multicenter retrospective cohort of consecutive aspirin-treated adults undergoing burr-hole craniotomy plus subdural drain for cSDH at four European centers, stratified into continuation, short-pause (≤5 d), and long-pause (>5 d) prior to surgery groups. The primary endpoints were postoperative hemorrhagic events within 48 h and thromboembolic events reported within 1 month. Secondary endpoints included Glasgow Outcome scale (GOS) at discharge/1 month, modified Rankin Scale (mRS) at 6 months, length of stay (LOS), 3-month recurrence, reoperation, and 1-month mortality.<h4>Results</h4>One hundred forty patients were analyzed (continuation n = 24; short pause n = 47; long pause n = 69). Baseline characteristics were balanced except for higher perioperative desmopressin in the continuation group (54.2% vs 8.5% vs 1.5%; p < 0.001). Among 104 patients with 1-month data, 6 acute (≤48 h) hemorrhagic events (5.8%) occurred: 4/19 (21.1%) with continuation versus 0/40 (0%) and 2/45 (4.4%) with short and long pause (three-group p = 0.005). Pooled, continuation versus any discontinuation gave 4/19 (21.1%) vs 2/85 (2.4%) (Fisher p = 0.010; unadjusted OR 9.70, 95% CI 1.88-49.91; adjusted OR 11.58, 95% CI 1.40-95.39, p = 0.023, after controlling for age, Charlson Comorbidity Index [CCI], baseline mRS, desmopressin, and prophylactic indication). The sensitivity analysis excluding desmopressin recipients (n = 88) showed a consistent direction of effect (continuation 2/9, 22.2% vs discontinuation 2/79, 2.5%; Fisher p = 0.05). Only one thromboembolic event (1.0%) occurred in the continuation group. Functional outcomes favored discontinuation (GOS at 1 month p = 0.004; mRS at 6 months p = 0.004). LOS, 3-month recurrence (8/104, 7.7%; p = 0.88), reoperation, and mortality did not differ significantly.<h4>Conclusions</h4>In this real-world multicenter cohort, perioperative continuation of aspirin was associated with a higher rate of 48-hour acute postoperative hemorrhagic events after burr-hole craniotomy for cSDH, while no advantage of pause > 5 days over ≤ 5 days was detected. Thromboembolic events were rare, and no association with aspirin status was found. Prospective studies and meta-analyses are warranted to establish evidence-based guidelines on perioperative aspirin management in cSDH.
Background
This paper addresses the management of aspirin therapy in elderly patients undergoing burr-hole drainage for chronic subdural hematoma (cSDH). Prior knowledge indicates that cSDH is common in this population, but the optimal timing for aspirin discontinuation remains unclear. Understanding the effects of aspirin management on postoperative complications is crucial for improving patient outcomes.
Methods
This was a multicenter retrospective cohort study involving consecutive aspirin-treated adults undergoing burr-hole craniotomy plus subdural drain for cSDH at four European centers. Patients were stratified into three groups based on the timing of aspirin discontinuation: continuation, short-pause (≤5 days), and long-pause (>5 days). Primary endpoints included postoperative hemorrhagic events within 48 hours and thromboembolic events reported within one month.
Results
Among 140 patients analyzed, 6 acute hemorrhagic events (5.8%) occurred within 48 hours. The continuation group experienced 4 out of 19 events (21.1%), while no events were reported in the short-pause group and 2 out of 45 (4.4%) in the long-pause group (three-group p=0.005). The study also reported one thromboembolic event (1.0%) in the continuation group, with functional outcomes favoring discontinuation.
Interpretation
The findings suggest that continuing aspirin therapy may lead to a higher rate of postoperative hemorrhagic events compared to discontinuation, aligning with some prior studies. However, the clinical significance of the effect size should be considered, especially given the small sample sizes in some groups. Confounding factors such as the retrospective nature of the study and the potential influence of desmopressin use limit the conclusions that can be drawn.
Key findings
- 6 acute (≤48 h) hemorrhagic events (5.8%) occurred: 4/19 (21.1%) with continuation versus 0/40 (0%) and 2/45 (4.4%) with short and long pause (three-group p = 0.005).
- Pooled, continuation versus any discontinuation gave 4/19 (21.1%) vs 2/85 (2.4%) (Fisher p = 0.010; unadjusted OR 9.70, 95% CI 1.88-49.91; adjusted OR 11.58, 95% CI 1.40-95.39, p = 0.023).
- Only one thromboembolic event (1.0%) occurred in the continuation group.
- Functional outcomes favored discontinuation (GOS at 1 month p = 0.004; mRS at 6 months p = 0.004).
- LOS, 3-month recurrence (8/104, 7.7%; p = 0.88), reoperation, and mortality did not differ significantly.
Limitations
- retrospective study design
- small sample size in some groups
- potential confounding factors not fully controlled
- single-site analysis may limit generalizability