Is it safe to administer aspirin (acetylsalicylic acid) after thrombectomy?

Aspirin Administration After Thrombectomy

Aspirin can be safely administered after thrombectomy, but timing should be based on post-procedural imaging to exclude hemorrhagic complications.

Evidence-Based Recommendations for Aspirin After Thrombectomy

Timing of Aspirin Administration

• For ischemic conditions treated with thrombectomy, delay aspirin administration until after the 24-hour post-thrombectomy scan has excluded internal bleeding 1
• Once hemorrhagic complications have been ruled out, aspirin should be started promptly to maintain cardiovascular protection, as gaps in aspirin therapy for more than 48 hours may lead to loss of cardioprotective effects 1

Safety Considerations

• Recent evidence suggests that intraprocedural intravenous aspirin in patients undergoing emergent stenting during mechanical thrombectomy does not increase symptomatic intracranial hemorrhage and is associated with good clinical outcomes 2
• In a study of 102 patients who underwent stenting during mechanical thrombectomy, those who received intravenous aspirin (500 mg) showed greater neurological improvement compared to those who did not receive aspirin 2
• Even when combined with thrombolysis, aspirin administration was not associated with increased bleeding risk 2

Dosing Recommendations

• Low-dose aspirin (81 mg) appears to be as effective as higher doses (325 mg) with potentially fewer side effects 3
• In the ADAPTABLE trial, which included patients with established cardiovascular disease (38% with diabetes), there were no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg versus 325 mg of aspirin daily 3
• Multiple studies in orthopedic surgery have demonstrated that low-dose aspirin is not inferior to high-dose aspirin for venous thromboembolism prophylaxis 4, 5

Special Considerations

• For patients with established cardiovascular disease, resuming aspirin therapy as soon as safely possible is important to reduce cardiovascular risk 1
• If the patient is on dual antiplatelet therapy for coronary stents, the American Heart Association recommends continuation of therapy if possible, as interruption increases risk of stent thrombosis 3
• For patients who underwent stenting during thrombectomy, aspirin administration is particularly important to prevent stent thrombosis 2

Implementation Algorithm

1. Immediate post-thrombectomy period:

   • Do not administer aspirin until post-procedural imaging (typically at 24 hours) confirms absence of hemorrhagic complications

2. After hemorrhage has been ruled out:

   • For patients with cardiovascular indications: Start aspirin at 81 mg daily
   • For patients who received stenting during thrombectomy: Start aspirin at 81 mg daily, potentially combined with a P2Y12 inhibitor based on stent type

3. Special situations:

   • If patient has atrial fibrillation requiring anticoagulation: Coordinate aspirin management with anticoagulation therapy
   • If patient has high bleeding risk: Consider gastric protection with proton pump inhibitors when administering aspirin 3

Potential Pitfalls and Caveats

• Avoid unnecessarily prolonged discontinuation of aspirin therapy in patients with cardiovascular disease, as this increases risk of thrombotic events 1
• For patients who received stenting during thrombectomy, dual antiplatelet therapy may be necessary, typically aspirin plus a P2Y12 inhibitor 2
• In patients with diabetes, "aspirin resistance" has been described, but current evidence does not support empirically using higher doses 3
• Always assess for occult bleeding before resuming aspirin 1

By following these evidence-based recommendations, aspirin can be safely administered after thrombectomy to provide cardiovascular protection while minimizing bleeding risk.