Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage.

BACKGROUND: Re-bleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. This is probably due to dissolution of the clot by natural fibrinolytic activity.

OBJECTIVES: The objective of this review was to assess the effect of antifibrinolytic treatment in patients with aneurysmal subarachnoid haemorrhage.

SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register and reference lists of articles. We also contacted drug companies.

SELECTION CRITERIA: Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid or an equivalent) with control in people with confirmed subarachnoid haemorrhage.

DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion and extracted the data. All five reviewers assessed trial quality.

MAIN RESULTS: Eight trials involving 937 patients were included. Based on 579 patients in two trials, antifibrinolytic treatment did not show any benefit for poor outcome (death, vegetative state or severe disability) with an odds ratio of 1.05, 95% confidence interval 0.76 to 1.46. Death from all causes was not significantly influenced by treatment across all eight trials (odds ratio 0.96, 95% confidence interval 0.72 to 1.26). Antifibrinolytic treatment reduced the risk of re-bleeding reported at the end of follow-up, with some heterogeneity between the trials (odds ratio 0.59, 95% confidence interval 0.42 to 0.81). Treatment increased the risk of cerebral ischaemia in four trials (odds ratio 2.03, 95% confidence interval 1.40 to 2.94). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus in four trials (odds ratio 1. 05, 95% confidence interval 0.71 to 1.56).

REVIEWER'S CONCLUSIONS: Antifibrinolytic treatment does not appear to benefit people with aneurysmal subarachnoid haemorrhage. However, the trials were all done more than 10 years ago. New strategies may counteract the ischaemia-inducing potential of antifibrinolytic treatment and lead to improved outcome. A trial of combined antifibrinolytic and anti-ischaemia treatment is underway.