Aspirin Continuation vs Discontinuation in Brain Surgery

Medscape

12-05-2025

Perioperative discontinuation of acetylsalicylic acid (ASA) treatment for 12 days was not associated with a reduction in 6-month recurrence of chronic subdural hematoma (cSDH) in older patients undergoing burr hole surgery compared with continued ASA use, according to new findings that challenges current practice norms.
METHODOLOGY:
The placebo-controlled, randomized SECA clinical trial included 155 adult patients (mean age, 78 years; 84% men) undergoing burr hole drainage for cSDH at six neurosurgical centers in Switzerland from February 2018 to June 2023. All received ASA treatment prior to the onset of cSDH.
Participants received continuous ASA treatment (100 mg/d; n = 78) or matching placebo (n = 77) for 12 days during the perioperative phase.
The primary outcome was the recurrence of cSDH necessitating reoperation within 6 months.
Secondary outcomes included cardiovascular or thromboembolic events, intracranial bleeding events, and mortality. Adverse events were monitored for 6 months.
TAKEAWAY:
The 6-month recurrence rates of cSDH did not differ significantly between the ASA (14%) and placebo (10%) groups. The recurrence rate with ASA was lower than previously reported estimates of 25%-33%.
The risk for cardiovascular, cerebrovascular, or thromboembolic events was slightly but not significantly lower in the ASA group than in the placebo group (hazard ratio [HR], 0.9; 95% CI, 0.5-1.8).
The risk for intracranial bleeding events other than recurrent cSDH was slightly but not significantly higher in the ASA group than in the placebo group (HR, 1.2; occurrence, six vs five participants), as was the risk for all-cause mortality (HR, 1.9; occurrence, four vs two participants). Any severe adverse event occurred in 7.7% vs 2.6%.
Results of sensitivity and per-protocol analyses were consistent with the main findings.
IN PRACTICE:
'Current clinical practice in cSDH is to discontinue blood thinner treatment, including ASA, before surgical treatment and to delay the resumption of ASA for at least 12-30 days after surgery,' the authors wrote. 'Based on this trial's data concerning the risk of recurrence and bleeding events vs the risk of cardiovascular or cerebrovascular and thromboembolic events, clinicians can conduct a data-driven risk-benefit analysis' to determine ASA continuation or discontinuation in their own patients undergoing the procedure, they added.
SOURCE:
This study was led by Maria Kamenova, MD, Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland. It was published online on April 27 in JAMA Neurology .
LIMITATIONS:
This trial had limited statistical power because of overestimated recurrence rates in the ASA group during trial design, which may have affected sample size estimation and subgroup analyses. Generalizability was limited to European populations and those undergoing burr hole drainage under aspirin therapy. Additionally, surgical technique variations across centers may have influenced outcomes, and the lack of follow-up imaging may have missed covert ischemic events.
DISCLOSURES:
This study was funded by the Swiss National Science Foundation, the Gottfried und Julia Bangerter-Rhyner-Stiftung, and the propatient Research Foundation of the University Hospital of Basel. Several investigators reported receiving support and having various ties with a number of sources, including pharmaceutical companies. Full details are provided in the original article.