We describe a clinical scenario of a postoperative ST-elevation myocardial infarction 2 h following craniotomy with tumor resection treated with aspiration thrombectomy and balloon dilation followed by a staged completion PCI 15 days later following the gradual introduction of P2Y12 inhibitor. To our knowledge, this staged approach has not been previously described, and it may provide temporizing therapy to patients with postoperative acute coronary syndrome at a high risk of bleeding until definitive revascularization can be completed.

Clopidogrel was selected as the preferred P2Y12 agent in this case to minimize the risk of intracranial bleeding [5]. The risk of bleeding was balanced against the risk of stent thrombosis which is associated with carriage of a reduced-function CYP2C19 allele [6]. CYP2C19 genetic testing was performed before the initiation of clopidogrel, identifying an intermediate metabolizer phenotype. Follow-up platelet aggregation studies were then performed to determine if sufficient platelet inhibition could be achieved with clopidogrel and aspirin therapy prior to proceeding with staged PCI. While CYP2C19 genotyping is not routinely performed in all patients with acute coronary syndromes undergoing PCI, selective testing—as performed in this case—may allow better risk quantification and stratification when competing risks are present.

There are conflicting data on the risks of postoperative intracranial bleeding in patients who continue aspirin in the perioperative period. One multicenter retrospective study reported a 2.6-fold increase in the rates of postoperative bleeding in patients undergoing open craniotomy for the repair of unruptured aneurysms who continued to take aspirin perioperatively [2]. A smaller single-center retrospective study showed no difference in bleeding complications for patients undergoing craniotomy with tumor resection who continued aspirin perioperatively [7].

The management of patients who do experience cardiovascular complications following neurosurgical procedures requires individualized risk–benefit analysis. There are limited human data for patients experiencing an acute thrombotic event to guide the safest timing of therapeutic anticoagulation resumption or initiation. An experimental animal model examining rats undergoing craniotomy and corticectomy identified a 30% rate of intracerebral hemorrhage in rats receiving therapeutic heparin (1.5–3 times control-activated partial thromboplastin time) on postoperative day 1 compared to a rate of 80% in rats receiving supratherapeutic (> 3 times control) doses of heparin [8]. A prior review of perioperative anticoagulation management in neurosurgery concluded that therapeutic anticoagulation can be initiated 3–5 days following neurosurgery in patients at the highest risk of thromboembolic events [9].

Patients with cancer face an elevated risk of developing cardiovascular complications, including higher morbidity and mortality associated with coronary artery disease [10,11,12]. Specifically, managing acute coronary syndrome (ACS) in patients with cancer and in the perioperative setting presents unique challenges due to their multiple comorbidities and increased bleeding risk. Additionally, the prognosis of these patients when undergoing invasive procedures for ACS is influenced by factors such as cancer type, staging, time since diagnosis, and ongoing oncological treatment [13,14,15]. Growing evidence shows that patients with cancer have worse in-hospital outcomes post-PCI with increased rates of major adverse cardiovascular events, 90-day readmission, and bleeding complications [11, 13, 16,17,18]. Long-term data showed a twofold higher rate of MI and repeat vascularization and a nearly threefold higher rate of stent thrombosis over 5 years post-PCI in patients with cancer [19].

The decision to pursue conservative medical management or an invasive strategy for patients with cancer and ACS is complex. It requires an individualized approach weighing the inherent risks of coronary revascularization procedures and the use of antiplatelets, guided by genetic testing when feasible. In 2016, the Society for Cardiovascular Angiography and Interventions (SCAI) issued a consensus document addressing special considerations of cardio-oncology patients in the cardiac catheterization laboratory, with respect to thrombocytopenia, coagulopathies, bleeding tendencies, vascular access complications, and increased stent thrombosis risk [20]. However, the management of ACS in this high-risk population needs more specific evidence-based guidelines calling for multidisciplinary collaboration and further research efforts to improve outcomes in cardio-oncology patients.