Can aspirin (acetylsalicylic acid) be started in a patient with a recent history of subdural hematoma (SDH) and burr hole surgery, presenting with chest pain?

Aspirin Administration in Recent Subdural Hematoma with Burr Hole Surgery

Do not start aspirin in this patient with recent subdural hematoma and burr hole surgery one month ago presenting with chest pain—recent bleeding is an absolute contraindication to aspirin administration, and the hemorrhagic risk outweighs potential cardiac benefits in this timeframe.

Critical Decision Framework

The American Heart Association guidelines explicitly state that aspirin should only be given to patients with suspected myocardial infarction when there is "no allergy or contraindication to aspirin, such as recent bleeding" 1. Your patient's subdural hematoma with burr hole surgery one month ago constitutes recent bleeding and represents a clear contraindication.

Why This Patient is High-Risk for Aspirin

• Recent intracranial hemorrhage with surgical intervention creates ongoing hemorrhagic vulnerability, particularly within the first several months post-operatively 2, 3
• Aspirin increases subdural hematoma recurrence risk significantly in neurosurgical patients, with hazard ratios as high as 12.8 in shunt patients 3
• The one-month timeframe is insufficient for complete healing of the subdural space and dural closure after burr hole surgery 4, 2

Immediate Management Algorithm

Step 1: Call EMS Immediately

• Activate emergency medical services for any patient with chest pain rather than attempting transport yourself 1
• This recommendation holds regardless of aspirin administration decision 5

Step 2: Assess for Cardiac vs Non-Cardiac Chest Pain

The AHA guidelines state that if you are uncertain or uncomfortable with aspirin administration, you should not encourage the person to take aspirin 1. In this case:

• Signs suggesting cardiac origin: shortness of breath, nausea, sweating, arm/back pain 1
• However, recent bleeding is an absolute contraindication that supersedes cardiac symptoms 1

Step 3: Defer to Advanced Care

• The decision to administer aspirin in cases with contraindications should be deferred to EMS providers with physician oversight 1
• Hospital-based physicians can weigh the immediate cardiac risk against rebleeding risk with neurosurgical consultation 1

Evidence on Aspirin and Subdural Hematoma

Hemorrhagic Risk Data

• Aspirin markedly increases subdural hematoma risk in neurosurgical patients, with 5-year survival estimates of 0.3 for aspirin users versus non-users (p < 0.0001) 3
• Recurrence rates are elevated in patients on antiplatelet therapy after subdural hematoma surgery 4, 2
• The timing of aspirin resumption after subdural hematoma surgery remains controversial, with most neurosurgeons discontinuing for at least 7 days perioperatively 2

Thromboembolic Risk Considerations

• While thromboembolic events are a concern in patients discontinuing aspirin, the literature shows that thromboembolic risk may be overestimated compared to rebleeding risk in the acute neurosurgical period 2
• One month post-burr hole is still considered high-risk for rebleeding, particularly if aspirin is introduced 4, 6

Common Pitfalls to Avoid

Pitfall 1: Assuming "Stable" Means Safe for Aspirin

• The neurosurgeon's assessment of "stable" refers to the current hematoma status, not clearance for antiplatelet therapy 4, 2
• Explicit neurosurgical clearance is required before restarting aspirin after subdural hematoma 1, 2

Pitfall 2: Prioritizing Cardiac Risk Over Hemorrhagic Risk

• The AHA guidelines specifically list recent bleeding as a contraindication because mortality from rebleeding can equal or exceed cardiac mortality in this population 1
• Neurosurgical complications from rebleeding (brain herniation, permanent disability) represent catastrophic outcomes 2, 3

Pitfall 3: Giving Aspirin Without Multidisciplinary Input

• The French Task Force on perioperative antiplatelet management emphasizes that decisions in high hemorrhagic risk scenarios (explicitly including neurosurgery) require joint decision-making between cardiologists and surgeons 1
• Document the contraindication clearly and ensure EMS/hospital teams are aware of the recent neurosurgical history 1

Alternative Cardiac Management

While aspirin is contraindicated, other interventions remain appropriate:

• Immediate EMS activation for rapid transport to cardiac-capable facility 1, 5
• Hospital-based alternatives may include clopidogrel (though also carries bleeding risk), heparin products, or primary PCI without antiplatelet pretreatment—decisions made by cardiology with neurosurgical input 1, 5
• Monitoring and supportive care during transport 1