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Antifibrinolytic therapy in the management of aneurismal subarachnoid hemorrhage revisited. A meta-analysis

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Abstract

Background

To reassess the use of antifibrinolytics (AF) in the management of aneurysmal subarachnoid hemorrhage (SAH) in the setting of present-day treatment strategies.

Method

The authors conducted a systematic review of the literature and a meta-analysis. They reviewed the PubMed database and conducted a manual review of article bibliographies.

Results

Using a pre-specified search strategy, 17 relevant studies involving a total of 2,872 patients with SAH at baseline, from which data of 1,380 patients having received AF, were included in a meta-analysis. Pooled odds ratios of the impact of AF on functional outcomes, rebleeding, and cerebral infarction were calculated. Short-term use of AF (72 h or less) associated with medical prevention of ischemic deficit seems to yield better results on functional outcome than long-term use of AF, especially if not associated with a medical prevention of ischemic deficit. The risk of cerebral infarction is not increased by the short-term use of AF and the risk of rebleeding is decreased independently of the length of AF use.

Conclusions

The use of AF should be reconsidered in the setting of modern-era treatment strategies, as the short-term use associated with medical prevention of ischemic deficit decreases the rate of rebleeding and does not increase the risk of cerebral infarction, thus potentially yielding better protection against poor functional outcome.

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Acknowledgements

We would like to express our gratitude to Dr Andrew F. Ducruet from Columbia University, NY, USA, for his prompt response to our questions.

Conflicts of interest

None.

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Authors and Affiliations

  1. Department of Neurosurgery, University Hospital of Caen, Faculty of Medicine, Avenue de la cote de Nacre, Caen, 14000, France

    Thomas Gaberel, Cristian Magheru, Evelyne Emery & Jean-Michel Derlon

  2. Inserm, Inserm U919, sérine protease and pathophysiology of the neurovascular unit, SP2U, UMR CNRS 6232, Centre d’Imagerie et de Neurosciences Appliquées aux Pathologies GIP Cyceron, University Caen Lower Normandy, bl Henri Becquerel, Caen, 14000, France

    Thomas Gaberel & Evelyne Emery

Authors
  1. Thomas Gaberel
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  2. Cristian Magheru
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  3. Evelyne Emery
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  4. Jean-Michel Derlon
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Corresponding author

Correspondence to Thomas Gaberel.

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Comment

The authors’ meta-analysis shows a decrease in rehemorrhage rates without any clear increase in stroke risk using short-term (<3 days) antifibrinolytic therapy (AF). The meta-analysis shows a trend towards fewer poor outcomes with short-term use of AF. In the older literature, patients were often actively dehydrated as part of the SAH management principles of the time, since hyponatremia was thought to be due to SIADH. Following the redescription of cerebral salt wasting and the description of hyperdynamic therapy in the early 1980s, patients were then hydrated following SAH, and this may well contribute to reduction in ischemic events over time. The current meta-analysis includes two recent papers not considered in the 2003 Cochrane Review: Hillman in 2002 and Starke in 2008. These two papers contain 753 patients and represent the most up-to-date treatment of subarachnoid hemorrhage. In the authors’ analysis, the results of short-term AF treatment and medical prevention of vasospasm described in these articles compare favorably to prior literature.

Patrick J. Connolly

Christopher M. Loftus

Philadelphia, Pennsylvania, USA

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Gaberel, T., Magheru, C., Emery, E. et al. Antifibrinolytic therapy in the management of aneurismal subarachnoid hemorrhage revisited. A meta-analysis. Acta Neurochir 154, 1–9 (2012). https://doi.org/10.1007/s00701-011-1179-y

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  • DOI: https://doi.org/10.1007/s00701-011-1179-y

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