Perioperative aspirin discontinuation prior to burr-hole drainage for chronic subdural hematoma: A European multicenter retrospective cohort study.

BACKGROUND: Chronic subdural hematoma (cSDH) frequently affects elderly patients receiving low-dose aspirin, yet the optimal perioperative management of aspirin before burr-hole drainage remains uncertain. We assessed whether the timing of aspirin discontinuation influences early postoperative hemorrhagic and thromboembolic events, functional outcome, recurrence, and length of stay (LOS).

METHODS: Multicenter retrospective cohort of consecutive aspirin-treated adults undergoing burr-hole craniotomy plus subdural drain for cSDH at four European centers, stratified into continuation, short-pause (≤5 d), and long-pause (>5 d) prior to surgery groups. The primary endpoints were postoperative hemorrhagic events within 48 h and thromboembolic events reported within 1 month. Secondary endpoints included Glasgow Outcome scale (GOS) at discharge/1 month, modified Rankin Scale (mRS) at 6 months, length of stay (LOS), 3-month recurrence, reoperation, and 1-month mortality.

RESULTS: One hundred forty patients were analyzed (continuation n = 24; short pause n = 47; long pause n = 69). Baseline characteristics were balanced except for higher perioperative desmopressin in the continuation group (54.2% vs 8.5% vs 1.5%; p < 0.001). Among 104 patients with 1-month data, 6 acute (≤48 h) hemorrhagic events (5.8%) occurred: 4/19 (21.1%) with continuation versus 0/40 (0%) and 2/45 (4.4%) with short and long pause (three-group p = 0.005). Pooled, continuation versus any discontinuation gave 4/19 (21.1%) vs 2/85 (2.4%) (Fisher p = 0.010; unadjusted OR 9.70, 95% CI 1.88-49.91; adjusted OR 11.58, 95% CI 1.40-95.39, p = 0.023, after controlling for age, Charlson Comorbidity Index [CCI], baseline mRS, desmopressin, and prophylactic indication). The sensitivity analysis excluding desmopressin recipients (n = 88) showed a consistent direction of effect (continuation 2/9, 22.2% vs discontinuation 2/79, 2.5%; Fisher p = 0.05). Only one thromboembolic event (1.0%) occurred in the continuation group. Functional outcomes favored discontinuation (GOS at 1 month p = 0.004; mRS at 6 months p = 0.004). LOS, 3-month recurrence (8/104, 7.7%; p = 0.88), reoperation, and mortality did not differ significantly.

CONCLUSIONS: In this real-world multicenter cohort, perioperative continuation of aspirin was associated with a higher rate of 48-hour acute postoperative hemorrhagic events after burr-hole craniotomy for cSDH, while no advantage of pause > 5 days over ≤ 5 days was detected. Thromboembolic events were rare, and no association with aspirin status was found. Prospective studies and meta-analyses are warranted to establish evidence-based guidelines on perioperative aspirin management in cSDH.