Pituitary apoplexy is a rare but life-threatening neurosurgical emergency, typically caused by acute hemorrhage or infarction of a pituitary adenoma within the sella turcica. It presents clinically with the sudden onset of severe headache, visual impairment and ophthalmoplegia. The present study reported the case of a 45-year-old male who experienced intermittent headaches and progressive right-sided visual deterioration over two months, with acute worsening in the preceding 6 h. The patient's medical history included coronary stent implantation and the patient had been on enteric-coated aspirin therapy for ~4 months. Magnetic resonance imaging and computed tomography of the head confirmed the diagnosis of pituitary apoplexy. The patient underwent emergency endoscopic transsphenoidal surgery, leading to significant improvement in right-sided vision. At the 6-month follow-up, the patient exhibited complete recovery with no evidence of tumor recurrence on imaging. This case highlights the importance of timely diagnosis and surgical intervention in achieving favorable outcomes in pituitary apoplexy and serves as a reminder for clinicians to consider the risk of hemorrhage in patients on long-term antiplatelet therapy.

The enhanced recovery after surgery (ERAS) approach to the surgical patient optimizes perioperative care to improve outcomes and facilitate recovery. Despite the success of ERAS in many surgical specialties, neurosurgery has been reluctant to adopt ERAS. The aim of this review was to examine recently published ERAS protocols for elective neurosurgical procedures with a focus on brain and spine surgeries.

There were few ERAS protocols published for brain and spine surgery in comparison to other surgical specialties. ERAS elements specific to brain surgery seem to address thromboprophylaxis planning, antiepileptic management, steroid administration, strict blood pressure control, and avoidance of mannitol. When implemented, protocols have yielded similar results to protocols for other surgical specialties, including reduced morbidity, hospital length of stay, and health care cost. However, widespread implementation was limited by difficulties in obtaining a consensus agreement on ERAS elements to include, achieving adoption across neurosurgeons, and protocol adherence.

While the adoption of ERAS in neurosurgery remains limited, emerging evidence supports its feasibility and effectiveness, particularly in reducing hospitalization costs and postoperative complications.

The perioperative management of chronic aspirin therapy in patients undergoing elective brain surgery is challenging due to the risk of bleeding and thromboembolic events. Although aspirin discontinuation reduces the bleeding risk, it can increase thrombotic complications, particularly in patients at high risk of cardiovascular complications. This Delphi study aimed to develop consensus-based guidelines to address these clinical challenges.

A 2-round Delphi survey was conducted among an international panel of 42 experienced anesthesiologists and neurosurgeons. Participants assessed the risks and benefits of perioperative aspirin management, including bleeding risk, thrombotic risk, timing of cessation and resumption, and the utility of platelet function testing. Consensus was defined as ≥80% agreement in round 2.

Round 1 highlighted significant variability in practice patterns. In round 2, consensus was reached on several key areas. Most experts (84%) agreed that continuing aspirin increases perioperative bleeding risk in high-risk procedures, with 87% recommending discontinuing aspirin 5 to 7 days before surgery. Nearly all experts (97%) supported continuing low-dose aspirin in high-thrombotic-risk patients. Conversely, for low-thrombotic-risk patients, only 65% agreed on aspirin continuation, reflecting an ongoing debate. No consensus was reached regarding routine platelet function testing.

This Delphi study provides experience-based recommendations for managing chronic aspirin therapy in neurosurgical patients. The panel strongly supports aspirin continuation in high-thrombotic-risk patients, with cessation 5 to 7 days before high-bleeding-risk surgeries. Individualized management is advised for low-bleeding-risk procedures and low-thrombotic-risk patients. Future research should further clarify aspirin management in these groups and explore the role of platelet function testing in neurosurgical settings.

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.