How long should aspirin (acetylsalicylic acid) be withheld after an iliopsoas retroperitoneal hematoma?

Management of Aspirin After Iliopsoas Retroperitoneal Hematoma

For aspirin used for secondary prevention (prior MI, stroke, or coronary stents), restart aspirin as soon as hemostasis is achieved or there is no further evidence of hemorrhage, typically within 24-48 hours of stabilization; for aspirin used for primary prevention only, permanently discontinue it.

Risk Stratification Based on Aspirin Indication

Secondary Prevention (High Thrombotic Risk)

• Aspirin should NOT be routinely stopped and must be restarted urgently once bleeding is controlled 1
• Patients with coronary stents, prior MI, or cerebrovascular disease face catastrophic thrombotic complications (fatal MI, disabling stroke) if aspirin is withheld beyond the acute bleeding phase 1
• Cohort studies demonstrate that patients who discontinued aspirin after major hemorrhage had significantly more cardiovascular events and deaths compared to those who continued, despite having fewer rebleeding events 1

Primary Prevention (Low Thrombotic Risk)

• Permanently discontinue aspirin 1
• The bleeding risk outweighs any cardiovascular benefit in this population 2

Timing of Aspirin Resumption

Immediate Management (First 24-48 Hours)

• Hold aspirin during active bleeding and acute resuscitation 2
• Aspirin irreversibly inhibits platelet function for 5-7 days, so stopping it provides immediate benefit in reducing ongoing hemorrhage 1
• Ensure hemodynamic stability and confirm hematoma is not expanding on repeat imaging before restarting 3

Resumption Timeline for Secondary Prevention

• Restart aspirin within 24-48 hours once hemostasis is achieved 1, 2, 4
• "Hemostasis achieved" is defined as: stable hemoglobin over 12-24 hours, no ongoing transfusion requirements, and imaging showing stable or resolving hematoma 2
• For patients with recent coronary stents (<12 months), aspirin should be restarted within 24 hours if at all possible, as the thrombotic risk is extremely high 1, 4

Extended Hold Period (If Necessary)

• If bleeding cannot be controlled or hematoma continues expanding, aspirin may need to be held longer, but should not exceed 5-7 days maximum 1, 2
• Beyond 5-7 days, thrombotic risk dramatically increases, particularly in patients with drug-eluting stents 1
• Consult interventional cardiology urgently if aspirin must be held beyond 48-72 hours in high-risk patients 1, 2

Special Considerations for Iliopsoas Hematoma

Monitoring for Rebleeding

• Iliopsoas hematomas can be fatal, with mortality rates of 5.6% at 7 days and 10.1% at 30 days in anticoagulated patients 3
• Even with therapeutic anticoagulation parameters, fatal exsanguination can occur within hours of initial bleeding 5
• Obtain repeat CT imaging 12-24 hours after aspirin resumption to ensure hematoma stability 3

Risk Factors That Increase Bleeding Risk

• Advanced age (>70 years), renal impairment, and concomitant antiplatelet or anticoagulant therapy significantly increase bleeding risk 6, 3
• Patients with myeloproliferative disorders paradoxically have increased bleeding risk despite elevated platelet counts 7
• One-third of spontaneous retroperitoneal hematomas occur in patients NOT taking anticoagulants, suggesting underlying vascular pathology 3

Management Algorithm

1. Confirm diagnosis with CT imaging showing iliopsoas/retroperitoneal hematoma 3
2. Immediately hold aspirin during active bleeding phase 2
3. Determine aspirin indication:
   • Secondary prevention → Plan to restart within 24-48 hours 1, 2, 4
   • Primary prevention → Permanently discontinue 1
4. Achieve hemostasis: Transfuse as needed, consider interventional radiology embolization if bleeding persists 3
5. Confirm stability: Stable hemoglobin × 12-24 hours, no ongoing transfusion needs 2
6. Restart aspirin (for secondary prevention) within 24-48 hours of hemostasis 1, 2, 4
7. Obtain repeat imaging 12-24 hours after aspirin resumption to confirm hematoma stability 3
8. If patient has coronary stents: Coordinate with interventional cardiology; consider continuing aspirin even during bleeding if stent is <1 month old 1

Critical Pitfalls to Avoid

• Do not withhold aspirin indefinitely in secondary prevention patients – the thrombotic risk (fatal MI, disabling stroke) exceeds rebleeding risk once hemostasis is achieved 1
• Do not restart aspirin if hematoma is still expanding – confirm stability with repeat imaging first 3
• Do not assume high platelet counts are protective – myeloproliferative disorders can paradoxically increase bleeding risk 7
• Do not delay cardiology consultation in stent patients – these patients require individualized management with potential for continuing aspirin throughout 1, 2