Craniolpasty and IHD

70+ yo male with previous meningioma. Now for cranioplasty for cosmetic purposes.


  • Meningioma – excised, followed by craniectomy for infected bone flap.
  • Metastatic bowel cancer (liver met)
  • AF
  • IHD
    • NSTEMI Feb ’21, precipitated by reduced exercise tolerance and angina.
    • On apixaban and aspirin (for AF and PCI)


  • Should surgery proceed?
    • Patient feels this will significantly add to his QoL
    • Plan pending for his metastatic bowel cancer, potential candidate for a partial liver resection in the future.
    • Oncologist suggests 2yr survival from the bowel cancer is reasonable (supporting decision for cranioplasty) and that this surgery won’t negatively affect his liver metastasis prognosis.
    • Craniectomy can be therapeutic in the setting of previous decompressive craniectomy, speeding neurocognitive recovery. Not relevant to this patient.
  • How to manage antiplatelet and anticoagulant agents, and timing since PCI for non-urgent surgery
    • NSx happy to perform procedure on aspirin
    • Discussed at anaesthetics-cardiology MDT – waiting until 12mth post PCI will not reduce this patient’s risk of MACE, especially if aspirin is able to continue perioperatively
    • Bridging not indicated. CHADS2 score = moderate risk. Evidence continues to support no bridging in this patient group due to increased bleeding risk without prevention of thromboembolic events.


  • Proceed to OT.
  • Continue aspirin.
  • Withhold anticoagulant. No bridging therapy.