Should I discontinue aspirin 30 mg twice daily for DVT prophylaxis in a patient with a recent subdural hemorrhage?

Discontinue Aspirin Immediately in This Patient with Recent Subdural Hemorrhage

You should discontinue the aspirin 30 mg twice daily immediately in this patient with recent subdural hemorrhage who is not yet cleared for chemical DVT prophylaxis. The neurology note explicitly states mechanical DVT prophylaxis only, which directly contradicts continuing any antiplatelet or anticoagulant therapy during the acute period after subdural hemorrhage.

Primary Guideline Recommendation

All anticoagulants and antiplatelets must be discontinued during the acute period for at least 1-2 weeks after subdural hemorrhage 1. This is a Class III recommendation (meaning treatment is not useful or effective and may be harmful) with Level of Evidence B 1.

• The American Heart Association/American Stroke Association explicitly states that for patients who develop subdural hematoma, all antiplatelet agents should be discontinued during the acute period 1
• This recommendation applies regardless of the indication for antiplatelet therapy 1

Clinical Reasoning for This Patient

Why Aspirin Must Be Stopped

• Subdural hemorrhage has significantly higher expansion risk with antiplatelet therapy: Research demonstrates that patients with subdural hemorrhage have a 9.1% rate of intracranial hemorrhage expansion when given antithrombotic medication, compared to 0% in other types of intracranial hemorrhage (P = 0.045) 2
• Aspirin increases subdural hematoma risk: Meta-analysis of 155,554 participants confirms aspirin increases the relative risk of subdural hematoma by 1.5-fold (95% CI 1.1-2.0, p = 0.01) 3
• The neurology team has already made the clinical determination that this patient is NOT cleared for chemical prophylaxis, which supersedes any discharge summary medication list 1

The DVT Prophylaxis Dilemma

While DVT prophylaxis is important, mechanical prophylaxis alone is the appropriate strategy during the acute subdural hemorrhage period:

• Sequential compression devices and early mobilization should be used instead of pharmacologic prophylaxis 1
• The 1-2 week period of mechanical-only prophylaxis represents an acceptable risk-benefit balance given the high risk of hemorrhage expansion 1, 2

Timeline for Potential Reinitiation

Do not restart any antiplatelet or anticoagulant therapy until:

1. Minimum 1-2 weeks have elapsed since the subdural hemorrhage 1
2. Neurology or neurosurgery explicitly clears the patient for chemical DVT prophylaxis
3. Repeat neuroimaging confirms stability of the subdural hemorrhage without expansion 1

If DVT Prophylaxis Becomes Absolutely Necessary

If the patient develops compelling indications for anticoagulation before the 1-2 week period:

• Intravenous heparin may be safer than oral agents because it can be rapidly titrated and reversed if rebleeding occurs 1
• However, this should only be considered after 3-4 weeks in most cases, with rigorous monitoring 1
• Half-dose anticoagulation has been reported as a potential compromise in case reports of patients with recurrent subdural hematoma who develop life-threatening VTE 4, though this is not guideline-supported

Critical Pitfalls to Avoid

• Do not assume the discharge summary is correct: Medication reconciliation errors are common, and the neurology note takes precedence as the most recent specialist assessment 1
• Do not restart aspirin "just for DVT prophylaxis": Aspirin is not recommended as primary DVT prophylaxis and provides minimal benefit compared to mechanical measures in this context 1
• Do not delay discontinuation: Every day of continued aspirin exposure increases the risk of subdural hematoma expansion 2

Documentation and Communication

• Contact the prescribing physician to clarify the discrepancy between the neurology note and discharge summary
• Document the clinical decision to discontinue aspirin based on guideline recommendations for subdural hemorrhage 1
• Ensure mechanical DVT prophylaxis (sequential compression devices) is actively ordered and being used 1
• Schedule neurology follow-up to determine when chemical prophylaxis can be safely restarted 1