🩸 Bleeding Risk [Neurosurgery Wiki]

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====== 🩸 Bleeding Risk ======

===== 📌 Definition =====
**[[Bleeding]] [[risk]]** refers to the **likelihood that a patient will experience [[hemorrhagic complication]]s**, either [[spontaneous]]ly or as a result of surgical [[procedure]]s or [[medication]]s (e.g., anticoagulants, antiplatelets, NSAIDs).

It is a critical consideration in **[[perioperative planning]]**, [[pain management]], and in the use of [[drug]]s that affect [[coagulation]] or platelet function.

===== 🧮 Risk Stratification =====

==== 🔺 High Bleeding Risk ====
  * Intracranial surgery (e.g., [[craniotomy]], tumor resection)
  * [[Spinal surgery]]
  * Recent [[gastrointestinal bleeding]]
  * Active [[peptic ulcer]]
  * Severe [[thrombocytopenia]] (<50,000/μL)
  * [[INR]] > 1.5 or aPTT > 1.5× normal
  * [[Dual antiplatelet therapy]]
  * Use of NSAIDs + anticoagulants
  * Liver failure or known coagulopathy

==== 🟠 Moderate Bleeding Risk ====
  * [[Biopsy]] procedures
  * [[Endoscopic]] interventions
  * Minor orthopedic surgery
  * Single-agent [[antiplatelet]] therapy
  * INR 1.2–1.5

==== 🟢 Low Bleeding Risk ====
  * Superficial skin procedures
  * Ophthalmic surgery
  * Dental extractions
  * No anticoagulant or antiplatelet use
  * Normal platelet count and coagulation profile

===== 💊 Drug-Related Considerations =====

^ Drug Class ^ Mechanism ^ Bleeding Risk ^
| NSAIDs (non-selective) | COX-1 inhibition → ↓ platelet aggregation | Mild to moderate ↑ |
| COX-2 inhibitors | Minimal effect on platelets | Low ↑ |
| Aspirin | Irreversible COX-1 inhibition | Moderate ↑ (dose-dependent) |
| Clopidogrel, Ticagrelor | P2Y12 receptor blockade | High ↑ |
| Warfarin | Vitamin K antagonist | High ↑ |
| DOACs (apixaban, rivaroxaban) | Direct factor Xa inhibition | High ↑ |
| Heparins | Antithrombin-mediated inhibition | High ↑ |

===== 🧠 Relevance in Neurosurgery =====
  * Even **minor bleeding** can have **devastating neurological consequences**
  * **NSAID use** post-craniotomy must be carefully assessed:
    - Meta-analysis (Cardoso et al., 2025) shows **no significant increase** in postoperative bleeding with NSAIDs vs. non-NSAIDs
  * Always weigh **analgesic benefit** vs. **hemorrhagic risk**

===== 🛠️ Assessment Tools (Optional) =====
  * HAS-BLED (for atrial fibrillation anticoagulation risk)
  * Preoperative coagulation panel: INR, aPTT, platelets
  * Review of medication history (esp. over-the-counter NSAIDs)

===== 📋 Prevention and Management =====
  * Preoperative risk stratification
  * Avoid high-risk medications in high-bleeding-risk surgeries
  * Optimize hemostasis intraoperatively
  * Use reversal agents if needed (e.g., vitamin K, PCC, platelets)
  * Monitor closely in ICU or step-down units

===== 📌 Summary =====
**Bleeding risk** is a dynamic, multifactorial concept.  
Its proper assessment is essential to balancing the **efficacy and safety** of surgical procedures and medications—especially in **high-stakes fields like neurosurgery**.

===== Systematic Reviews and Meta-Analysis =====

Concerns remain about their [[safety]], particularly regarding the risk of postoperative [[bleeding]] because of [[cyclooxygenase]] inhibition. 
A Systematic Review and Meta-Analysis aimed to evaluate whether NSAIDs increase the risk of hemorrhagic [[complication]]s after [[craniotomy]] for [[brain surgery]] when compared with non-NSAID approaches or [[placebo]].

A [[systematic search]] was conducted in PubMed, Scopus, Web of Science, and Cochrane databases to identify studies comparing NSAIDs with non-NSAID drugs for postoperative analgesia after craniotomy for brain surgery. End points were (1) all bleeding complications and (2) bleeding complications requiring surgical intervention. Subanalyses focused on randomized controlled trials (RCTs) and patients undergoing tumor resection. Risk ratios (RR) and risk difference (RD) with 95% CI were pooled using a random-effects model, and heterogeneity was assessed with the I2 statistic.

Seven studies (5 RCTs), including 2251 patients (1119 males; median ages ranging from 11 to 55 years), of whom 583 (25.9%) received NSAIDs, met the inclusion criteria. Surgical indications included [[tumor resection]], [[aneurysm clipping]], and [[microsurgery]] for [[brain arteriovenous malformation]]s. No significant differences were observed between NSAID and non-NSAID groups for overall bleeding complications (RR: 1.05; 95% CI: 0.58, 1.93; I2 = 0%; RD: 0.31%; 95% CI: -1.46%, 0.84%) or bleeding complications requiring surgical intervention (RR: 1.27; 95% CI: 0.51, 3.16; I2 = 0%; RD: 0.03%; 95% CI: -0.90%, 0.97%). Similar results were found in the RCT-only and tumor resection subanalyses.

The findings suggest that NSAIDs are a safe option for [[postoperative analgesia]] in patients undergoing [[craniotomy]] for [[brain surgery]], because they do not significantly increase the risk of [[bleeding complications]], including those requiring [[neurosurgical intervention]], compared with non-NSAID analgesics
((Cardoso LJC, Ferreira MY, Faria IC, Martins KAM, Calisaya-Madariaga IG, Teixeira IPS, Teixeira EM, Suffren B, Oliveira FGF, Croft Z, Rychen J, Ferreira C, Martinez-Perez R, Langer D, Boockvar JA. Do [[Nonsteroidal Anti-Inflammatory Drug]]s Increase [[Bleeding Risk]] After [[Craniotomy]] for [[Brain Surgery]]? A Systematic Review and Meta-Analysis. Neurosurgery. 2025 Jun 2. doi: 10.1227/neu.0000000000003541. Epub ahead of print. PMID: 40454849.)).
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