What is the recommended management of aspirin (acetylsalicylic acid) in a patient with a history of cerebrovascular accident (CVA) who is scheduled for surgery?

From the Guidelines

Aspirin should not be discontinued preoperatively in patients with a history of cerebrovascular accident (CVA) who are taking it for secondary prevention, except for procedures with a high risk of bleeding, as the risk of recurrent stroke outweighs the bleeding risk 1. When managing aspirin in patients with a history of CVA who are scheduled for surgery, it is essential to consider the risks and benefits of continuing or discontinuing the medication.

• The risk of thrombotic events, including recurrent stroke, increases significantly when aspirin is discontinued, and this risk generally outweighs the slightly increased bleeding risk during surgery.
• For most non-neurological, non-cardiac surgeries, the increased bleeding is usually manageable and less dangerous than a potential recurrent cerebrovascular event.
• However, for procedures with extremely high bleeding risk (neurosurgery, spinal surgery, or certain ophthalmologic procedures), a brief interruption may be considered after consultation between the surgeon, anesthesiologist, and neurologist. Key considerations include:
• The patient's individual risk factors for bleeding and thrombosis
• The type and urgency of the surgery
• The potential consequences of bleeding or thrombotic complications Aspirin should be maintained at the patient's usual dose (commonly 81-325 mg daily) without interruption before, during, and after surgery, unless a high bleeding risk procedure is planned, in which case a brief interruption may be necessary, and the medication should be restarted as soon as hemostasis is achieved, typically within 24 hours after surgery 1.

From the Research

Aspirin Management in Patients with CVA for Surgery

The management of aspirin in patients with a history of cerebrovascular accident (CVA) who are scheduled for surgery is a complex issue. Several studies have investigated the optimal management of aspirin in this context.

• Patients taking aspirin for the primary prevention of cardiovascular disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding 2.
• Patients with established cardiovascular disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery 2.
• For patients with a history of CVA, the decision to hold or continue aspirin should be made on a case-by-case basis, taking into account the individual patient's risk of bleeding and thromboembolism 2, 3.
• Some studies suggest that stopping low-dose aspirin 10 days or longer prior to spine surgery may be recommended to avoid postoperative epidural hematoma/paralysis 4.
• The type of treatment, heparin vs antiplatelet agents, does not appear to affect either stroke risk or injury healing rates in patients with blunt cerebrovascular injuries 5.

Considerations for Aspirin Cessation or Continuation

When deciding whether to hold or continue aspirin in patients with CVA for surgery, several factors should be considered, including:

• The patient's individual risk of bleeding and thromboembolism
• The type of surgery being performed
• The patient's medical history, including the presence of coronary artery disease or other cardiovascular conditions
• The potential benefits and risks of aspirin cessation or continuation in the perioperative period 2, 3.