DISCONTINUING low-dose aspirin (ASA) perioperatively in chronic subdural hematoma (cSDH) patients undergoing burr hole surgery does not significantly reduce recurrence rates, according to the SECA randomised clinical trial, challenging previous assumptions about bleeding risks.
Chronic subdural hematoma, a condition prevalent in older adults, often requires surgical evacuation, but managing perioperative antiplatelet therapy remains contentious. Balancing bleeding recurrence risks against cardiovascular complications from ASA interruption is critical, yet prior evidence lacked rigour. The SECA trial addressed this by randomising 155 Swiss patients aged ≥66 (mean 77.7 years, 16% female) undergoing cSDH surgery to continuous ASA (78 participants) or placebo (77) for 12 days postoperatively. All had pre-existing ASA use for cardiovascular prevention.
At six months, recurrence rates requiring reoperation were 13.9% in the ASA group versus 9.5% with placebo, showing no statistically significant difference (weighted risk difference 4.4%; 95% CI −7.2% to 15.9%; P=0.56)13. Cardiovascular/thromboembolic events occurred at 0.27 vs 0.28 per person half-year, respectively, with a non-significant trend towards higher events in placebo (0.06 vs 0.02 for ASA-indicated events)15. Mortality (0.06 vs 0.03) and bleeding rates (0.10 vs 0.08) were comparable1. Notably, recurrence risks under continued ASA were lower than historical estimates, suggesting prior observational studies overestimated hazards35.
These findings indicate that routine ASA discontinuation may be unnecessary for cSDH surgery patients, as it fails to curb recurrence while potentially elevating cardiovascular risks. Clinicians should prioritise individual thrombotic risk assessment over blanket cessation. Future research must identify high-recurrence subgroups and clarify long-term cardiovascular impacts, possibly through larger trials powered for secondary endpoints. Integrating these results into guidelines could reduce unwarranted treatment interruptions, optimising outcomes in this frail population.
Reference
Kamenova M et al. Aspirin continuation or discontinuation in surgically treated chronic subdural hematoma: a randomized clinical trial.. JAMA Neurol. 2025;DOI:10.1001/jamaneurol.2025.0850.
