Management of Aspirin in Elderly Patient with Traumatic Head Hematoma
Yes, aspirin should be held immediately in this elderly nursing home resident with a traumatic intracranial hematoma, and it should remain discontinued during the acute observation period until hemorrhage stability is confirmed on repeat imaging. 1
Immediate Management Protocol
Hold Aspirin and Initiate Monitoring
Discontinue aspirin 325 mg immediately upon diagnosis of the intracranial hematoma. 1 Patients on antiplatelet therapy with documented subdural hematomas have a 3-fold increased risk of hemorrhage progression, making aspirin cessation critical during the acute phase. 1
Admit for close neurological observation for 24-72 hours with serial clinical assessments. 1 The American College of Emergency Physicians guidelines specifically note that elderly patients (≥65 years) on aspirin with subdural hematomas require closer monitoring due to increased bleeding risk. 1
Monitor Glasgow Coma Scale (GCS) every 15 minutes for the first 2 hours, then hourly for the following 12 hours, documenting individual GCS components and pupillary size/reactivity at each evaluation. 1
Repeat Imaging Requirements
Obtain repeat head CT at 6-8 hours after the initial scan to assess for hemorrhage expansion. 1 This is non-negotiable in antiplatelet-exposed patients, even if neurologically stable, as clinical examination alone is insufficient to rule out progression. 1
If any neurological deterioration occurs (GCS decline ≥2 points, pupillary changes, posturing, or new focal deficits), obtain immediate repeat CT scanning. 1
Evidence Supporting Aspirin Discontinuation
The decision to hold aspirin is supported by multiple lines of evidence showing increased bleeding risk, though the data reveals important nuances:
A 2008 trauma study found an 18% mortality rate in elderly patients with intracranial hemorrhage while on aspirin or clopidogrel, with initial GCS and CT grade being the strongest predictors of death. 2 While hemorrhage progression after admission was unusual (occurring in only 4 of 81 patients), the mortality risk when progression did occur was substantial. 2
Interestingly, a 2003 prospective study of 231 patients over age 60 found that low-dose aspirin (100 mg/day) did not increase the frequency of traumatic intracranial hemorrhage compared to controls (24.5% vs 25.6%), and surgical intervention rates were similar (4.5% vs 4.1%). 3 However, this study examined initial hemorrhage occurrence, not progression risk once hemorrhage is already present.
A 2014 prospective study using propensity-matched controls found that low-dose aspirin (81 mg) was not associated with progression on repeat CT (25% vs 16.6% in non-aspirin patients, p>0.05) or clinical deterioration. 4 However, this patient is on 325 mg daily—a four-fold higher dose—which carries greater bleeding risk than the 81 mg studied.
Critical Thresholds for Neurosurgical Consultation
Immediate neurosurgical consultation is warranted if any of the following develop: 1
- GCS decline of ≥2 points
- Pupillary changes or posturing
- New focal neurological deficits
- Significant hemorrhage expansion on repeat imaging
- Failure to show neurological improvement within 72 hours
When to Consider Aspirin Resumption
Do not restart aspirin until hemorrhage stability is documented on repeat imaging and the patient demonstrates consistent neurological stability. 1 The risk/benefit ratio must be reassessed after the observation period, weighing:
Cardiovascular indication strength: If aspirin was prescribed for secondary prevention after myocardial infarction or coronary stenting, the cardiovascular risk of discontinuation is substantial. The American College of Cardiology/American Heart Association states that aspirin withdrawal has been associated with recurrent acute coronary syndrome events. 5
Hemorrhage characteristics: Smaller, stable hematomas with no progression on 6-8 hour repeat CT carry lower risk than expanding or large hematomas.
Dose optimization: If aspirin resumption is deemed necessary for high-risk cardiovascular disease, switch from 325 mg to 81 mg daily, as the American College of Cardiology/American Heart Association prefers the 81 mg dose because it provides equivalent cardiovascular protection with lower bleeding risk. 5
Common Pitfalls to Avoid
Do not discharge based solely on normal neurological examination—documented intracranial hematomas require admission and repeat imaging regardless of clinical stability. 1
Do not assume a single negative repeat CT at 6-8 hours guarantees safety—antiplatelet therapy significantly increases the risk of delayed hemorrhage progression, and observation should continue for 24-72 hours. 1
Do not restart aspirin prematurely (within 48-72 hours) without documented hemorrhage stability, even in patients with coronary artery disease. The immediate bleeding risk outweighs short-term cardiovascular risk in the acute post-trauma period. 1
Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion during the observation period. 1
Special Consideration for High-Risk Cardiac Patients
If this patient has coronary stents or recent acute coronary syndrome, cardiology consultation is essential before prolonged aspirin discontinuation. 5 The American College of Cardiology/American Heart Association recommends that aspirin should never be interrupted in patients with coronary stents, as it reduces major adverse cardiac events. 5 However, in the setting of active intracranial hemorrhage, the immediate bleeding risk supersedes cardiovascular concerns during the initial 24-72 hour stabilization period. 1
After hemorrhage stability is confirmed, if aspirin must be resumed for compelling cardiovascular indications, restart at 81 mg (not 325 mg) within 24-48 hours of documented stability, and consider proton pump inhibitor co-therapy to reduce gastrointestinal bleeding risk. 5