Balancing bleeding, thrombosis and myocardial injury: A call for balance and precision medicine for aspirin in neurosurgery

Perioperative management of antiplatelet therapy involves a delicate balancing of the risk of periprocedural blood loss with the cardiovascular and thrombotic risk to the patient. Due to the unique nature of neurosurgery, perioperative bleeding may have devastating consequences and cause major morbidity and mortality. The recommendation to discontinue aspirin prior to major neurosurgical procedures rests upon conventional practice, expert consensus with priority given to avoidance of any major bleed. On the contrary recent prospective data do not support the existence of additional bleeding risk in patients continuing aspirin compared to those who stop aspirin prior to procedure. Patients with cardiovascular and metabolic comorbidities are increasingly encountered in the operation theatre these days. In these patients, prevention of myocardial injury after non-cardiac surgery (MINS) is an important focus for perioperative risk reduction. Prolonged (≥ 7 days) cessation of antiplatelets is one of the most important predictors of MINS. This complicated milieu of risks and benefits highlights the difficulty of practicing evidence-based medicine and minimizing harm in patients on aspirin needing neurosurgery.