Abstract & Commentary
Source: Roos Y, et al. Antifibrinolytic therapy for aneurysmal subarachnoid hemorrhage. A major update of a cochrane review. Stroke. 2003;34:2308-2309.
In current clinical practice, the surgical or endovascular treatment of aneurysmal subarachnoid hemorrhage (SAH) often is delayed for clinical or logistic reasons. Rebleeding is an important cause of death and disability following SAH and probably is caused by dissolution of the thrombus within the aneurysm by activation of the fibrinolytic system. Therefore, antifibrinolytics have been used to reduce the risk of rebleeding. Roos and associates reviewed the effect of antifibrinolytic treatment in patients with aneurysmal SAH. They searched the Cochrane Files Register and the medical literature, and also contacted drug companies in order to find randomized trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid, or an equivalent) with control in patients with confirmed SAH. Nine trials involving approximately 1400 patients were included. Three trials involving more than 1000 patients assessed outcome in terms of both case fatality and degree of dependence. In these 3 trials, antifibrinolytic treatment had no beneficial effect on outcome. Death from all causes was not significantly influenced by treatment across all 9 trials. Although antifibrinolytic treatment reduced the risk of rebleeding at the end of follow-up in all trials, treatment increased the risk of cerebral ischemia in 5 trials. Antifibrinolytic treatment had no effect on the reported rate of hydrocephalus in 5 trials. The conclusion of Roos et al was that treatment with antifibrinolytics did not improve overall outcome because the reduction in the rate of rebleeding was offset by an increase in cerebral ischemic events.
These findings are important because they do not support the routine use of antifibrinolytic drugs in patients with aneurysmal SAH. Although antifibrinolytic treatment caused a 40% reduction in rebleeding, there was no effect on poor outcome (death, persistent vegetative state, or severe disability), and there was an increased incidence of cerebral ischemia in treated patients compared with controls. The full text of the review is available in the Cochrane Library, issue 2, 2003, or online at www.update-software.com/Cochrane. — John J. Caronna, Vice-Chairman, Department of Neurology, Cornell University Medical Center; Professor of Clinical Neurology, New York Hospital; Associate Editor, Neurology Alert.