🩸 Bleeding Risk

Bleeding risk refers to the likelihood that a patient will experience hemorrhagic complications, either spontaneously or as a result of surgical procedures or medications (e.g., anticoagulants, antiplatelets, NSAIDs).

It is a critical consideration in perioperative planning, pain management, and in the use of drugs that affect coagulation or platelet function.

• 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

• Biopsy procedures
• Endoscopic interventions
• Minor orthopedic surgery
• Single-agent antiplatelet therapy
• INR 1.2–1.5

• Superficial skin procedures
• Ophthalmic surgery
• Dental extractions
• No anticoagulant or antiplatelet use
• Normal platelet count and coagulation profile

• Even minor bleeding can have devastating neurological consequences
• NSAID use post-craniotomy must be carefully assessed:
  1. 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

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

• 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

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.

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 complications 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 malformations. 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 ¹⁾.