Reducing the risk of rebleeding before early aneurysm surgery: a possible role for antifibrinolytic therapy
- 1 February 1997
- journal article
- Published by Journal of Neurosurgery Publishing Group (JNSPG) in Journal of Neurosurgery
- Vol. 86 (2) , 220-225
- https://doi.org/10.3171/jns.1997.86.2.0220
Abstract
Previous studies on the initial nonoperative management of aneurysmal subarachnoid hemorrhage (SAH) demonstrated that antifibrinolytic therapy reduced the risk of rebleeding by approximately 50%; however, prolonged antifibrinolytic treatment was associated with an increase in the incidence of hydrocephalus and delayed ischemic deficit. When early surgical intervention became routine for ruptured aneurysms, the use of antifibrinolytic therapy diminished. However, early surgery is generally performed in the first several days after SAH and the risk of rebleeding remains until the aneurysm is obliterated. Based on a review of the literature, the authors formed two hypotheses: 1) the high-dose intravenous administration of epsilon-aminocaproic acid (EACA), an antifibrinolytic agent, might reduce the risk of recurrent hemorrhage in the interval between SAH and early surgical intervention, and 2) a short course of EACA might not produce the increase in complications previously associated with its prolonged administration. The use of preoperative high-dose EACA therapy was evaluated in 307 patients to determine its safety and efficacy in reducing the incidence of rebleeding before early aneurysm surgery. All patients were admitted within 3 days of their SAH and were classified as Hunt and Hess Grades I to III. Only four patients (1.3%) suffered a recurrent hemorrhage. This compares favorably to the rebleeding rate of 5.7% reported for the early surgery group in the International Cooperative Study on the Timing of Aneurysm Surgery. The incidence of hydrocephalus or symptomatic vasospasm was not unduly elevated in patients receiving preoperative EACA. Thirty-five patients (11.4%) needed temporary cerebrospinal fluid drainage during their hospitalization and, overall, 8.8% required a ventriculoperitoneal shunt. The mean age of the patients who required a shunt was nearly 10 years older than the general study population. Seventy-one patients (23%) developed symptomatic vasospasm and 8.1% suffered a stroke. This study indicates that a brief course of high-dose EACA is safe and may be beneficial in diminishing the risk of rebleeding in good-grade patients prior to early surgical intervention. Further investigation is planned based on these promising results.Keywords
This publication has 54 references indexed in Scilit:
- FIBRINOLYTIC ACTIVITY OF THE CEREBROSPINAL FLUID AFTER SUBARACHNOID HAEMORRHAGEActa Neurologica Scandinavica, 2009
- Hemodilution for cerebral ischemia.Stroke, 1989
- The natural history of aneurysms and arteriovenous malformationsJournal of Neurosurgery, 1985
- Antifibrinolytic Treatment in Subarachnoid HemorrhageNew England Journal of Medicine, 1984
- Antifibrinolytic therapy in the acute period following aneurysmal subarachnoid hemorrhageJournal of Neurosurgery, 1984
- Quantitative Determination of Plasma Fibrinolytic Activity in Patients with Ruptured Intracranial Aneurysms Who Are Receiving ϵ-Aminocaproic Acid: Relationship of Possible Complications of Therapy to the Degree of Fibrinolytic InhibitionNeurosurgery, 1984
- Myopathy induced by epsilon-aminocaproic acidJournal of Neurosurgery, 1982
- Do antifibrinolytic agents prevent rebleeding after rupture of a cerebral aneurysm? A reviewClinical Neurology and Neurosurgery, 1980
- Subarachnoid HemorrhageNew England Journal of Medicine, 1978
- Intracranial Aneurysms and Subarachnoid Hemorrhage. A Cooperative Study. Antifibrinolytic Therapy in Recent Onset Subarachnoid HemorrhageStroke, 1975