Is aspirin (acetylsalicylic acid) contraindicated in a patient with a history of brain tumor and prior craniotomy, presenting with an unresponsive episode?

From the Guidelines

Aspirin is contraindicated in a patient with a history of brain tumor and prior craniotomy, presenting with an unresponsive episode, due to the increased risk of intracranial bleeding. Given the patient's history of craniotomy and the new neurological symptom, there is concern about potential intracranial bleeding risk, which could be increased by aspirin's antiplatelet effects 1. Before considering any antiplatelet therapy, the patient should undergo urgent neurological evaluation including brain imaging to rule out recurrent tumor, seizure activity, or intracranial bleeding as causes of the unresponsive episode. Some key points to consider in the management of such patients include:

• The administration of antiepileptic drugs (AEDs) to patients with brain tumors who have not had seizures is common despite the lack of definitive evidence that the potential benefits might outweigh the side effects of AEDs 1.
• Primary prophylaxis with anticonvulsants is not recommended because it has not been shown to be effective in preventing a first-ever seizure 1.
• Patients who experienced a seizure should receive secondary anticonvulsant prophylaxis, at least transiently 1.
• The risk of intracranial bleeding is probably not increased in brain metastasis patients in general treated with therapeutic doses of low-molecular-weight heparin (LMWH) 1. If intracranial bleeding is present or suspected, aspirin should be avoided entirely. If the episode was determined to be a transient ischemic attack and imaging shows no bleeding risk, low-dose aspirin (81mg daily) might be considered after consultation with both neurology and neurosurgery 1. The decision to use aspirin must balance the potential cardiovascular benefits against the heightened bleeding risk in someone with prior brain surgery and possible ongoing neurological issues. Alternative antiplatelet agents or different approaches to cardiovascular risk reduction might be safer options depending on the specific clinical scenario.

From the Research

Aspirin Contraindication in Patients with Brain Tumor and Prior Craniotomy

• The use of aspirin in patients with a history of brain tumor and prior craniotomy is a complex issue, with several studies investigating its safety and efficacy 2, 3, 4.
• A study published in the Journal of thrombosis and haemostasis found that antiplatelet medications, including aspirin, were not associated with an increased risk of intracranial hemorrhage (ICH) in patients with primary brain tumors 2.
• Another study published in the Journal of neurosurgery found that perioperative aspirin use was not associated with an increased rate of hemorrhagic complications following intracranial tumor surgery 4.
• However, the risk of ICH is still a concern, and patients with a history of brain tumor and prior craniotomy should be closely monitored for signs of bleeding 3, 5, 6.

Postoperative Complications and Aspirin Use

• Postoperative complications, including neurological and non-neurological events, are common after craniotomy for brain tumor surgery 6.
• The use of aspirin in the perioperative period may not increase the risk of hemorrhagic complications, but it is essential to weigh the benefits and risks of aspirin use in each individual patient 4.
• Factors such as intraoperative bleeding, absence of preoperative motor deficit, and posterior fossa surgery may increase the risk of postoperative neurological complications 6.

Blood Pressure Management and Aspirin Use

• Postoperative blood pressure management is crucial in patients with a history of brain tumor and prior craniotomy, as acute hypertension can occur in up to 90% of patients 5.
• The use of aspirin may not be directly related to blood pressure management, but it is essential to consider the overall clinical context and the patient's individual risk factors when making decisions about aspirin use 4, 5.