Perioperative management of a neurosurgical patient with a meningioma and recent coronary artery stent

Patients who undergo placement of a drug-eluting coronary artery stent are prescribed dual antiplatelet therapy for one year. Early cessation of this therapy is a risk factor for a major adverse cardiac event, especially in high-risk patients. The perioperative physician team must evaluate the risk of surgical bleeding relative to the thrombotic risk during the perioperative period in patients taking dual antiplatelet therapy who must undergo intracranial neurosurgery. A 67 year old woman presented with right-sided hearing loss. Neurologic examination was significant for early papilledema and decreased hearing in the right ear. Magnetic resonance imaging showed a > 5 cm contrast-enhancing mass within her right-middle fossa with surrounding vasogenic edema and midline shift. Additional medical history was significant for diabetes, hypertension, and placement of a drug-eluting stent for coronary artery disease three months before her initial presentation. Medications included aspirin and clopidogrel. She underwent embolization of the middle meningeal arterial supply to the meningioma, then was admitted to the hospital for perioperative management of her antiplatelet therapy and telemetry monitoring. Her clopidogrel was stopped and aspirin continued perioperatively. An intravenous infusion of the antiplatelet drug, eptifibatide, replaced clopidogrel and was continued until 8 hours prior to surgical incision. During resection of the meningioma, no unusual surgical bleeding was noted. The patient was discharged on postoperative day 3 with satisfactory recovery.