Treatment of subarachnoid hemorrhage from ruptured intracranial aneurysm with tranexamic acid: a double-blind clinical trial

Tranexamic acid for patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of 2991 patients

OBJECTIVE

We aimed to synthesize evidence from published clinical trials on the efficacy and safety of tranexamic acid (TXA) administration in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We followed the standard methods of the Cochrane Handbook of Systematic Reviews for interventions and the PRISMA statement guidelines 2020 when conducting and reporting this study. A computer literature search of PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted from inception until 1 January 2022. We selected observational studies and clinical trials comparing TXA versus no TXA in aSAH patients. Data of all outcomes were pooled as the risk ratio (RR) with the corresponding 95% confidence intervals in the meta-analysis models.

RESULTS

Thirteen studies with a total of 2991 patients were included in the analysis. TXA could significantly cut the risk of rebleeding (RR 0.56, 95% CI 0.44 to 0.72) and mortality from rebleeding (RR 0.60, 95% CI 0.39 to 0.92, p = 0.02). However, TXA did not significantly improve the overall mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus (all p > 0.05). In terms of safety, no significant adverse events were reported. No statistical heterogeneity or publication bias was found in all outcomes.

CONCLUSION

In patients with aSAH, TXA significantly reduces the incidence of rebleeding and mortality from rebleeding. However, current evidence does not support any benefits in overall mortality, neurological outcome, delayed cerebral ischemia, or hydrocephalus.

The efficacy of antifibrinolytic therapy in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Aim

The efficacy of antifibrinolytics in subarachnoid hemorrhage remains unclear due to conflicting evidence from studies.

Materials & methods

Online databases were queried to include randomized controlled trials and propensity matched observational studies. We used Review Manager for the statistical analysis, presenting results as odds ratios with 95% CI.

Results

The 12 shortlisted studies included 3359 patients, of which 1550 (46%) were in the intervention (tranexamic acid) group and 1809 (54%) in the control group. Antifibrinolytic therapy significantly reduced the risk of rebleeding (OR: 0.55; 95% CI: 0.40-0.75; p = 0.0002) with no significant decrease in poor clinical outcome (OR: 1.02; 95% CI: 0.86-1.20; p = 0.85) and all-cause mortality (OR: 0.92; CI: 0.72-1.17; p = 0.50).

Conclusion

In patients with subarachnoid hemorrhage, antifibrinolytics reduce the risk of rebleeding without significantly affecting mortality or clinical outcomes.

Efficacy and safety of tranexamic acid in intracranial haemorrhage: A meta-analysis

BACKGROUND

Although some studies have shown that tranexamic acid is beneficial to patients with intracranial haemorrhage, the efficacy and safety of tranexamic acid for intracranial haemorrhage remain controversial.

METHOD

The PubMed, EMBASE, and Cochrane Library databases were systematically searched. The review followed PRISMA guidelines. Data were analyzed using the random-effects model.

RESULTS

Twenty-five randomized controlled trials were included. Tranexamic acid significantly inhibited hematoma growth in intracranial hemorrhage (ICH) and traumatic brain injury (TBI) patients. (ICH: mean difference -1.76, 95%CI -2.78 to -0.79, I2 = 0%, P < .001; TBI: MD -4.82, 95%CI -8.06 to -1.58, I2 = 0%, P = .004). For subarachnoid hemorrhage (SAH) patients, it significantly decreased the risk of hydrocephalus (OR 1.23, 95%CI 1.01 to 1.50, I2 = 0%, P = .04) and rebleeding (OR, 0.52, 95%CI 0.35 to 0.79, I2 = 56% P = .002). There was no significance in modified Rankin Scale, Glasgow Outcome Scale 3-5, mortality, deep vein thrombosis, pulmonary embolism, or ischemic stroke/transient ischemic.

CONCLUSION

Tranexamic acid can significantly reduce the risk of intracranial haemorrhage growth in patients with ICH and TBI. Tranexamic acid can reduce the incidence of complications (hydrocephalus, rebleeding) in patients with SAH, which can indirectly improve the quality of life of patients with intracranial haemorrhage.

Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage

BACKGROUND

Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably related to the dissolution of the blood clot at the site of the aneurysm rupture by natural fibrinolytic activity. This review is an update of previously published Cochrane Reviews.

OBJECTIVES

To assess the effects of antifibrinolytic treatment in people with aneurysmal subarachnoid haemorrhage.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (May 2022), CENTRAL (in the Cochrane Library 2021, Issue 1), MEDLINE (December 2012 to May 2022), and Embase (December 2012 to May 2022). In an effort to identify further published, unpublished, and ongoing studies, we searched reference lists and trial registers, performed forward tracking of relevant references, and contacted drug companies (the latter in previous versions of this review).

SELECTION CRITERIA

Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid, or an equivalent) with control in people with subarachnoid haemorrhage of suspected or proven aneurysmal cause.

DATA COLLECTION AND ANALYSIS

Two review authors (MRG & WJD) independently selected trials for inclusion, and extracted the data for the current update. In total, three review authors (MIB & MRG in the previous update; MRG & WJD in the current update) assessed risk of bias. For the primary outcome, we dichotomised the outcome scales into good and poor outcome, with poor outcome defined as death, vegetative state, or (moderate) severe disability, assessed with either the Glasgow Outcome Scale or the Modified Rankin Scale. We assessed death from any cause, rates of rebleeding, delayed cerebral ischaemia, and hydrocephalus per treatment group. We expressed effects as risk ratios (RR) with 95% confidence intervals (CI). We used random-effects models for all analyses. We assessed the quality of the evidence with GRADE.

MAIN RESULTS

We included one new trial in this update, for a total of 11 included trials involving 2717 participants. The risk of bias was low in six studies. Five studies were open label, and we rated them at high risk of performance bias. We also rated one of these studies at high risk for attrition and reporting bias.  Five trials reported on poor outcome (death, vegetative state, or (moderate) severe disability), with a pooled risk ratio (RR) of 1.03 (95% confidence interval (CI) 0.94 to 1.13; P = 0.53; 5 trials, 2359 participants; high-quality evidence), which showed no difference between groups. All trials reported on death from all causes, which showed no difference between groups, with a pooled RR of 1.02 (95% CI 0.90 to 1.16; P = 0.77; 11 trials, 2717 participants; high-quality evidence). In trials that combined short-term antifibrinolytic treatment (< 72 hours) with preventative measures for delayed cerebral ischaemia, the RR for poor outcome was 0.98 (95% CI 0.81 to 1.18; P = 0.83; 2 trials, 1318 participants; high-quality evidence).  Antifibrinolytic treatment reduced the risk of rebleeding, reported at the end of follow-up (RR 0.65, 95% CI 0.47 to 0.91; P = 0.01; 11 trials, 2717 participants; absolute risk reduction 7%, 95% CI 3 to 12%; moderate-quality evidence), but there was heterogeneity (I² = 59%) between the trials. The pooled RR for delayed cerebral ischaemia was 1.27 (95% CI 1.00 to 1.62; P = 0.05; 7 trials, 2484 participants; moderate-quality evidence). However, this effect was less extreme after the implementation of ischaemia preventative measures and < 72 hours of treatment (RR 1.10, 95% CI 0.83 to 1.46; P = 0.49; 2 trials, 1318 participants; high-quality evidence). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus (RR 1.09, 95% CI 0.99 to 1.20; P = 0.09; 6 trials, 1992 participants; high-quality evidence).

AUTHORS' CONCLUSIONS

The current evidence does not support the routine use of antifibrinolytic drugs in the treatment of people with aneurysmal subarachnoid haemorrhage. More specifically, early administration with concomitant treatment strategies to prevent delayed cerebral ischaemia does not improve clinical outcome. There is sufficient evidence from multiple randomised controlled trials to incorporate this conclusion in treatment guidelines.

Safety and Efficacy of Tranexamic Acid in Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis of Randomized Controlled Trials

Background

In recent decades, tranexamic acid (TXA) antifibrinolytic therapy before aneurysm clipping or embolization has been widely reported, but its safety and efficacy remain controversial. This meta-analysis evaluated the efficacy and safety of TXA therapy in aneurysmal subarachnoid hemorrhage (aSAH) patients, aiming to improve the evidence-based medical knowledge of treatment options for such patients.

Methods

Pubmed, Web of Science, and Cochrane Library databases were searched up to 1 March 2021 for randomized controlled trials (RCTs). We extracted safety and efficacy outcomes and performed a meta-analysis using the Review Manager software. We performed two group analyses of TXA duration and daily dose.

Results

Ten RCT studies, enrolling a total of 2,810 participants (1,410 with and 1,400 without TXA therapy), matched the selection criteria. In the TXA duration group: TXA did not reduce overall mortality during the follow-up period [RR 1.00 (95% CI 0.81–1.22)]. The overall rebleeding rate in the TXA group was 0.53 times that of the control group, which was statistically significant [RR 0.53 (95% CI 0.39–0.71)]. However, an RR of 0.43 was not statistically significant in the subgroup analysis of short-term therapy [RR 0.43 (95% CI 0.13–1.39)]. The overall incidence of hydrocephalus was significantly higher in the TXA group than in the control group [RR 1.13 (95% CI 1.02–1.24)]. However, the trend was not statistically significant in the subgroup analysis [short-term: RR 1.10 (95% CI 0.99–1.23); long-term: RR 1.22 (95% CI 0.99–1.50)]. Treatment with TXA did not cause significant delayed cerebral ischemia [RR 1.18 (95% CI 0.89–1.56)], and its subgroup analysis showed an opposite and insignificant effect [short-term: RR 0.99 (95% CI 0.79–1.25); long-term: RR 1.38 (95% CI 0.86–2.21)]. Results in the daily dose group were consistent with those in the TXA duration group.

Conclusions

Tranexamic acid does not reduce overall mortality in patients with aSAH, nor does it increase the incidence of delayed cerebral ischemia. Tranexamic acid in treating aSAH can reduce the incidence of rebleeding. However, there is no statisticalsignificance in the ultra-early short-term and low daily dose TXA therapy, which may be due to the lack of relevant studies, and more RCT experiments are needed for further study.

Systematic Review Registration:

https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO, identifier: 244079.

Efficacy and Safety of Tranexamic Acid in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Tranexamic acid has been shown to reduce rebleeding after aneurysmal subarachnoid hemorrhage; however, whether it can reduce mortality and improve clinical outcomes is controversial. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of the tranexamic acid in aneurysmal subarachnoid hemorrhage. We conducted a comprehensive literature search of PubMed, Embase, Web of Science, and Cochrane Library from inception to March 2021 for randomized controlled trials (RCTs) comparing tranexamic acid and placebo in adults with aneurysmal subarachnoid hemorrhage. The risk of bias was evaluated using the Cochrane Handbook, and the quality of evidence was evaluated using the GRADE approach. This meta-analysis included 13 RCTs, involving 2,888 patients. In patients with aneurysmal subarachnoid hemorrhage tranexamic acid had no significant effect on all-cause mortality (RR = 0.96; 95% CI = 0.84–1.10, p = 0.55, I² = 44%) or poor functional outcome (RR = 1.04; 95% CI = 0.95–1.15, p = 0.41) compared with the control group. However, risk of rebleeding was significantly lower (RR = 0.59; 95% CI = 0.43–0.80, p = 0.0007, I² = 53%). There were no significant differences in other adverse events between tranexamic acid and control treatments, including cerebral ischemia (RR = 1.17; 95% CI = 0.95–1.46, p = 0.15, I² = 53%). At present, routine use of tranexamic acid after subarachnoid hemorrhage cannot be recommended. For a patient with subarachnoid hemorrhage, it is essential to obliterate the aneurysm as early as possible. Additional higher-quality studies are needed to further assess the effect of tranexamic acid on patients with subarachnoid hemorrhage.

Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine

Purpose

To develop evidence-based clinical practice recommendations regarding transfusion practices and transfusion in bleeding critically ill adults.

Methods

A taskforce involving 15 international experts and 2 methodologists used the GRADE approach to guideline development. The taskforce addressed three main topics: transfusion support in massively and non-massively bleeding critically ill patients (transfusion ratios, blood products, and point of care testing) and the use of tranexamic acid. The panel developed and answered structured guideline questions using population, intervention, comparison, and outcomes (PICO) format.

Results

The taskforce generated 26 clinical practice recommendations (2 strong recommendations, 13 conditional recommendations, 11 no recommendation), and identified 10 PICOs with insufficient evidence to make a recommendation.

Conclusions

This clinical practice guideline provides evidence-based recommendations for the management of massively and non-massively bleeding critically ill adult patients and identifies areas where further research is needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06531-x.

Tranexamic acid in non-traumatic intracranial bleeding: a systematic review and meta-analysis

Non-traumatic intracranial bleeding (NTIB), comprising subarachnoid hemorrhage (SAH) and intra-cranial bleeding (ICH) is a significant public health concern. Tranexamic acid (TXA) is a promising treatment with benefits yet to be fully demonstrated. We conducted a systematic review and meta-analysis on the impact of TXA on mortality in NTIB. We searched the PubMed, Cochrane Library, Google Scholar and ScienceDirect databases for studies reporting mortality data following the use of TXA in NTIB for comparisons with a control group. We computed random-effect meta-analysis on estimates of risk and sensitivity analyses. We computed meta-regression to examine the putative effects of the severity of NTIB, sociodemographic data (age, sex), and publication date. Among potentially 10,008 articles, we included 15 studies representing a total of 4883 patients: 2455 receiving TXA and 2428 controls; 1110 died (23%) during the follow-up. The meta-analysis demonstrated a potential of 22% decrease in mortality for patients treated by TXA (RR = 0.78, 95%CI 0.58-0.98, p = 0.002). Meta-regression did not demonstrate any influence of the severity of NTIB, age, sex, length of treatment or date of publication. Sensitivity analyses confirmed benefits of TXA on mortality. TXA appears to be a therapeutic option to reduce non-traumatic intracranial bleeding mortality, particularly in patients with SAH.

Association of Intravenous Tranexamic Acid With Thromboembolic Events and Mortality: A Systematic Review, Meta-analysis, and Meta-regression

IMPORTANCE

Tranexamic acid (TXA) is an efficient antifibrinolytic agent; however, concerns remain about the potential adverse effects, particularly vascular occlusive events, that may be associated with its use.

OBJECTIVE

To examine the association between intravenous TXA and total thromboembolic events (TEs) and mortality in patients of all ages and of any medical disciplines.

DATA SOURCE

Cochrane Central Register of Controlled Trials and MEDLINE were searched for eligible studies investigating intravenous TXA and postinterventional outcome published between 1976 and 2020.

STUDY SELECTION

Randomized clinical trials comparing intravenous TXA with placebo/no treatment. The electronic database search yielded a total of 782 studies, and 381 were considered for full-text review. Included studies were published in English, German, French, and Spanish. Studies with only oral or topical tranexamic administration were excluded.

DATA EXTRACTION AND SYNTHESIS

Meta-analysis, subgroup and sensitivity analysis, and meta-regression were performed. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

MAIN OUTCOMES AND MEASURES

Vascular occlusive events and mortality.

RESULTS

A total of 216 eligible trials including 125 550 patients were analyzed. Total TEs were found in 1020 (2.1%) in the group receiving TXA and 900 (2.0%) in the control group. This study found no association between TXA and risk for total TEs (risk difference = 0.001; 95% CI, -0.001 to 0.002; P = .49) for venous thrombosis, pulmonary embolism, venous TEs, myocardial infarction or ischemia, and cerebral infarction or ischemia. Sensitivity analysis using the risk ratio as an effect measure with (risk ratio = 1.02; 95% CI, 0.94-1.11; P = .56) and without (risk ratio = 1.03; 95% CI, 0.95-1.12; P = .52) studies with double-zero events revealed robust effect size estimates. Sensitivity analysis with studies judged at low risk for selection bias showed similar results. Administration of TXA was associated with a significant reduction in overall mortality and bleeding mortality but not with nonbleeding mortality. In addition, an increased risk for vascular occlusive events was not found in studies including patients with a history of thromboembolism. Comparison of studies with sample sizes of less than or equal to 99 (risk difference = 0.004; 95% CI, -0.006 to 0.014; P = .40), 100 to 999 (risk difference = 0.004; 95% CI, -0.003 to 0.011; P = .26), and greater than or equal to 1000 (risk difference = -0.001; 95% CI, -0.003 to 0.001; P = .44) showed no association between TXA and incidence of total TEs. Meta-regression of 143 intervention groups showed no association between TXA dosing and risk for venous TEs (risk difference, -0.005; 95% CI, -0.021 to 0.011; P = .53).

CONCLUSIONS AND RELEVANCE

Findings from this systematic review and meta-analysis of 216 studies suggested that intravenous TXA, irrespective of dosing, is not associated with increased risk of any TE. These results help clarify the incidence of adverse events associated with administration of intravenous TXA and suggest that TXA is safe for use with undetermined utility for patients receiving neurological care.

Subarachnoid hemorrhage rebleeding in the first 24 h is associated with external ventricular drain placement and higher grade on presentation: Cohort study

BACKGROUND

Rebleeding after aneurysmal subarachnoid hemorrhage (aSAH) confers a poor prognosis; however, risk factors and differential outcomes associated with early rebleeding in the first 24 h after symptom presentation are incompletely understood.

METHODS

A retrospective cohort study of all aSAH presenting to our institution between 2001 and 2016 was performed. Early rebleeding events were defined as clinical neurologic decline with radiographically confirmed acute intracranial hemorrhage within 24 h after symptom presentation. Univariate and multivariate logistic regression analyses were used to assess clinical associations, with a specific focus on baseline Glasgow Coma Score (GCS), World Federation of Neurosurgical Societies (WFNS), and modified Fisher scores.

RESULTS

Of 471 aSAH cases, 33 (7%) experienced early rebleeding. Multivariate regression identified extraventricular drain (EVD) placement (OR = 2.16, P = 0.04) and WFNS 3-5 (OR = 2.69, P = 0.02) as significant predictors of early rebleeding. Good functional outcomes were observed in 8 patients with early rebleeding (24%), all of whom underwent aneurysm treatment. Higher SAH grade prior to rebleeding (WFNS 3-5) was significantly associated with increased odds of an unfavorable functional outcome (OR = 8.09, P < 0.01). Anticoagulation, aneurysm size and location were not significantly associated with either early rebleeding incidence or functional outcome.

CONCLUSIONS

Early rebleeding in aSAH is associated with unfavorable functional outcomes. EVD placement and higher SAH grade on presentation appear to be significantly and independently associated with increased risk of rebleeding within first 24 h, as well as unfavorable long-term functional outcome; however, the clinical benefit of hyper-acute aneurysm treatment requires further investigation.

Tranexamic Acid Inhibits Hematoma Expansion in Intracerebral Hemorrhage and Traumatic Brain Injury. Does Blood Pressure Play a Potential Role? A Meta-Analysis from Randmized Controlled Trials

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic agent, which has shown an effect on reducing blood loss in many diseases. Many studies focus on the effect of TXA on cerebral hemorrhage, however, whether TXA can inhibit hematoma expansion is still controversial. Our meta-analysis performed a quantitative analysis to evaluate the efficacy of TXA for the hematoma expansion in spontaneous and traumatic intracranial hematoma.

METHOD

Pubmed (MEDLINE), Embase, and Cochrane Library were searched from January 2001 to May 2020 for randomized controlled trials (RCTs).

RESULT

We pooled 3102 patients from 7 RCTs to evaluate the efficacy of TXA for hematoma expansion. Hematoma expansion (HE) rate and hematoma volume (HV) change from baseline were used to analyze. We found that TXA led to a significant reduction in HE rate (P = 0.002) and HV change (P = 0.03) compared with the placebo. Patients with moderate or serious hypertension benefit more from TXA. (HE rate: P = 0.02, HV change: P = 0.04) TXA tends to have a better efficacy on HV change in intracerebral hemorrhage (ICH). (P = 0.06) CONCLUSIONS: TXA showed good efficacy for hematoma expansion in spontaneous and traumatic intracranial hemorrhage. Patients with moderate/severe hypertension and ICH may be more suitable for TXA administration in inhibiting hematoma expansion .

Prevention of Early Recurrence of Aneurysmal Subarchnoid Haemorrhage by Tranexamic Acid: A Controlled Clinical Trial

A controlled clinical trial of Tranexamic Acid (TEA) was underaken to as sess its effectiveness in reducing early recurrence of haemorrhage in patients with aneurysmal subarchnoid haemorrhge (SAH). The series of control patients and patients having TEA which were consecutive. Of the 65 patients treated with TEA recurrence occurred in six (9%) and five patients died from recur rence of haemorrhage. Of the 64 patients in the control group, 17 (26%) pa tients had recurrent haemorrhage and eight patients died from it. Administra tion of tranexamic acid is found to have significantly reduced the early recur rence of haemorrhage.

Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage

BACKGROUND

Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably related to dissolution of the blood clot at the site of aneurysm rupture by natural fibrinolytic activity. This review is an update of a previously published Cochrane review.

OBJECTIVES

To assess the effects of antifibrinolytic treatment in people with aneurysmal subarachnoid haemorrhage.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (1948 to December 2012), and EMBASE (1947 to December 2012). In an effort to identify further published, unpublished, and ongoing studies we searched reference lists and trial registers, performed forward tracking of relevant references and 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 subarachnoid haemorrhage of suspected or proven aneurysmal cause.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion and extracted the data. Three review authors assessed trial quality. For the primary outcome we converted the outcome scales between good and poor outcome for the analysis. We scored death from any cause and rates of rebleeding, cerebral ischaemia, and hydrocephalus per treatment group. We expressed effects as risk ratios (RR) with 95% confidence intervals (CI). We used random-effects models for all analyses.

MAIN RESULTS

We included 10 trials involving 1904 participants. The risk of bias was low in six studies. Four studies were open label and were rated as high risk of performance bias. One of these studies was also rated as high risk for attrition bias. Four trials reported on poor outcome (death, vegetative state, or severe disability) with a pooled risk ratio (RR) of 1.02 (95% confidence interval (CI) 0.91 to 1.15). All trials reported on death from all causes with a pooled RR of 1.00 (95% CI 0.85 to 1.18). In a trial that combined short-term antifibrinolytic treatment (< 72 hours) with preventative measures for cerebral ischaemia the RR for poor outcome was 0.85 (95% CI 0.64 to 1.14). Antifibrinolytic treatment reduced the risk of re-bleeding reported at the end of follow-up (RR 0.65, 95% CI 0.44 to 0.97; 78 per 1000 participants), but there was heterogeneity (I² = 62%) between the trials. The pooled RR for reported cerebral ischaemia was 1.41 (95% CI 1.04 to 1.91, 83 per 1000 participants), again with heterogeneity between the trials (I² = 52%). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus in five trials (RR 1.11, 95% CI 0.90 to 1.36).

AUTHORS' CONCLUSIONS

The current evidence does not support the use of antifibrinolytic drugs in the treatment of people with aneurysmal subarachnoid haemorrhage, even in those who have concomitant treatment strategies to prevent cerebral ischaemia. Results on short-term treatment are promising, but not conclusive. Further randomised trials evaluating short-term antifibrinolytic treatment are needed to evaluate its effectiveness.

The spot sign and tranexamic acid on preventing ICH growth--AUStralasia Trial (STOP-AUST): protocol of a phase II randomized, placebo-controlled, double-blind, multicenter trial

RATIONALE

No evidence-based acute therapies exist for intracerebral hemorrhage. Intracerebral hemorrhage growth is an important determinant of patient outcome. Tranexamic acid is known to reduce hemorrhage in other conditions.

AIM

The study aims to test the hypothesis that intracerebral hemorrhage patients selected with computed tomography angiography contrast extravasation 'spot sign' will have lower rates of hematoma growth when treated with intravenous tranexamic acid within 4.5-hours of stroke onset compared with placebo.

DESIGN

The Spot sign and Tranexamic acid On Preventing ICH growth--AUStralasia Trial is a multicenter, prospective, 1:1 randomized, double-blind, placebo-controlled, investigator-initiated, academic Phase II trial. Intracerebral hemorrhage patients fulfilling clinical criteria (e.g. Glasgow Coma Scale >7, intracerebral hemorrhage volume <70 ml, no identified secondary cause of intracerebral hemorrhage, no thrombotic events within the previous 12 months, no planned surgery) and demonstrating contrast extravasation on computed tomography angiography will receive either intravenous tranexamic acid 1 g 10-min bolus followed by 1 g eight-hour infusion or placebo. A second computed tomography will be performed at 24 ± 3 hours to evaluate intracerebral hemorrhage growth and patients followed up for three-months.

STUDY OUTCOMES

The primary outcome measure is presence of intracerebral hemorrhage growth by 24 ± 3 hours, defined as either >33% or >6 ml increase from baseline, and will be adjusted for baseline intracerebral hemorrhage volume. Secondary outcome measures include growth as a continuous measure, thromboembolic events, and the three-month modified Rankin Scale score.

DISCUSSION

This is the first trial to evaluate the efficacy of tranexamic acid in intracerebral hemorrhage patients selected based on an imaging biomarker of high likelihood of hematoma growth. The trial is registered as NCT01702636.

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

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.

Management of bleeding in patients with advanced cancer

Bleeding occurs in up to 10% of patients with advanced cancer. It can present in many different ways. This article provides a qualitative review of treatment options available to manage visible bleeding. Local modalities, such as hemostatic agents and dressings, radiotherapy, endoscopic ligation and coagulation, and transcutaneous arterial embolization, are reviewed in the context of advanced cancer, as are systemic treatments such as vitamin K, vasopressin/desmopressin, octreotide/somatostatin, antifibrinolytic agents (tranexamic acid and aminocaproic acid), and blood products. Considerations at the end of life are described.

Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage

BACKGROUND

Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding 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, the Cochrane Controlled Trials Register, Medline and Embase (last searched June 2002) 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

Nine trials involving 1399 patients were included. Based on 1041 patients in three trials, antifibrinolytic treatment did not show any evidence of benefit for poor outcome (death, vegetative state or severe disability) with an odds ratio of 1.12, 95% confidence interval 0.88 to 1.43. Death from all causes was not significantly influenced by treatment across all nine trials (odds ratio 0.99, 95% confidence interval 0.79 to 1.24). Antifibrinolytic treatment reduced the risk of re-bleeding reported at the end of follow-up, with some heterogeneity between the trials (odds ratio 0.55, 95% confidence interval 0.42 to 0.71). Treatment increased the risk of cerebral ischaemia in five trials (odds ratio 1.39, 95% confidence interval 1.07 to 1.82) with considerable heterogeneity between the most recent study (Roos 2000), in which specific treatments to prevent cerebral ischemia were used, and the four older studies. Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus in five trials (odds ratio 1.14, 95% confidence interval 0.86 to 1.51).

REVIEWER'S CONCLUSIONS

Treatment does not improve clinical outcome because the benefit is offset by an increase in poor outcome caused by cerebral ischemia as a result of treatment with antifibrinolytics. These data do not support the routine use of antifibrinolytic drugs in the treatment of patients with aneurysmal subarachnoid haemorrhage.

Tranexamic acid: a review of its use in surgery and other indications

Tranexamic acid is a synthetic derivative of the amino acid lysine that exerts its antifibrinolytic effect through the reversible blockade of lysine binding sites on plasminogen molecules. Intravenously administered tranexamic acid (most commonly 10 mg/kg followed by infusion of 1 mg/kg/hour) caused reductions relative to placebo of 29 to 54% in postoperative blood losses in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), with statistically significant reductions in transfusion requirements in some studies. Tranexamic acid had similar efficacy to aprotinin 2 x 10(6) kallikrein inhibitory units (KIU) and was superior to dipyridamole in the reduction of postoperative blood losses. Transfusion requirements were reduced significantly by 43% with tranexamic acid and by 60% with aprotinin in 1 study. Meta-analysis of 60 trials showed tranexamic acid and aprotinin, unlike epsilon-aminocaproic acid (EACA) and desmopressin, to reduce significantly the number of patients requiring allogeneic blood transfusions after cardiac surgery with CPB. Tranexamic acid was associated with reductions relative to placebo in mortality of 5 to 54% in patients with upper gastrointestinal bleeding. Meta-analysis indicated a reduction of 40%. Reductions of 34 to 57.9% versus placebo or control in mean menstrual blood loss occurred during tranexamic acid therapy in women with menorrhagia; the drug has also been used to good effect in placental bleeding, postpartum haemorrhage and conisation of the cervix. Tranexamic acid significantly reduced mean blood losses after oral surgery in patients with haemophilia and was effective as a mouthwash in dental patients receiving oral anticoagulants. Reductions in blood loss were also obtained with the use of the drug in patients undergoing orthotopic liver transplantation or transurethral prostatic surgery, and rates of rebleeding were reduced in patients with traumatic hyphaema. Clinical benefit has also been reported with tranexamic acid in patients with hereditary angioneurotic oedema. Tranexamic acid is well tolerated; nausea and diarrhoea are the most common adverse events. Increased risk of thrombosis with the drug has not been demonstrated in clinical trials.

CONCLUSIONS

Tranexamic acid is useful in a wide range of haemorrhagic conditions. The drug reduces postoperative blood losses and transfusion requirements in a number of types of surgery, with potential cost and tolerability advantages over aprotinin, and appears to reduce rates of mortality and urgent surgery in patients with upper gastrointestinal haemorrhage. Tranexamic acid reduces menstrual blood loss and is a possible alternative to surgery in menorrhagia, and has been used successfully to control bleeding in pregnancy.

Fibrinolytic inhibitors for cancer-associated bleeding problems

This pilot study of 16 patients explored the use of two fibrinolytic inhibitors, tranexamic acid and aminocaproic acid, for the suppression of tumor-associated hemorrhage. The effects of such bleeding include anemia requiring transfusion, practical difficulties with dressings, and psychological morbidity from constant reminder of poor physical health. Cessation of bleeding occurred in 14 of the 16 patients treated. The average time until significant improvement in bleeding was just 2 days and the average time for complete cessation was 4 days. We conclude that fibrinolytic inhibitors are potentially useful agents in palliative care.

Fibrinolytic activity after subarachnoid haemorrhage and the effect of tranexamic acid

Seventy-four patients with recent subarachnoid haemorrhage were randomly allocated to placebo or tranexamic acid treatment. Fibrinolytic activity in the blood and cerebrospinal fluid was assessed before treatment, one week later and two weeks later. The natural history of fibrinolysis following subarachnoid haemorrhage was obtained from analysis of the placebo group. Following subarachnoid haemorrhage, fibrin degradation products and plasminogen activity in the cerebrospinal fluid were elevated. Subsequently, fibrin degradation products in the cerebrospinal fluid fell progressively over the following 2 weeks. Changes in cerebrospinal fluid plasminogen activity correlated with those of blood plasminogen activity. Complications such as rebleeding, hydrocephalus or cerebral thrombosis could not be predicted from analysis of fibrinolytic activity. Tranexamic acid treatment resulted in a reduction in cerebrospinal fluid and blood plasminogen activity. The relevance of fibrinolysis in cerebrospinal fluid and blood to the management of subarachnoid haemorrhage is discussed.

Benefits and risks of antifibrinolytic therapy in the management of ruptured intracranial aneurysms. A double-blind placebo-controlled study

One hundred patients with a verified subarachnoid haemorrhage were studied in a double blind, placebo-controlled trial at a single centre to determine the value and relative risks of tranexamic acid (TXA) in the management of ruptured intracranial aneurysms. The incidence of recurrent haemorrhage between active and placebo groups was identical (12%) and the mortality from recurrent haemorrhage was 7% and 5%, respectively. The overall incidence of cerebral infarction before surgery, at discharge and at 6 months follow-up was greater in the TXA group (27%) than in the control group (11%). Post-operative cerebral ischaemia was significantly more frequent in the active, 18 of 29 as compared to 6 of 32 patients, in the placebo group. In a fifth of the patients in whom cerebral blood flow was estimated there was a significant reduction of cerebral blood flow (CBF) on the side of the ruptured aneurysm in the TXA treated group. It is suggested that this may be the cause of the increased incidence of cerebral ischaemia in this group. There was no significant difference in the incidence of cerebral vasospasm, hydrocephalus, visual disturbances and gastrointestinal disturbances. More fatalities were encountered from ischaemia and recurrent haemorrhage in the TXA group but these differences did not reach statistical significance at the 5% level. Given that disability was due to either vasospasm or recurrent haemorrhage than a patient under TXA treatment was significantly more likely to have disability due to vasospasm (p less than 0.04); the reverse was true for the placebo patient (p less than 0.05).

Rebleeding, ischaemia and hydrocephalus following anti-fibrinolytic treatment for ruptured cerebral aneurysms: a retrospective clinical study

350 patients with subarachnoid haemorrhage from aneurysmal rupture--admitted in the years 1966-1983--were selected for a retrospective controlled study on the efficacy of antifibrinolytic therapy (AFT). Patients treated with antifibrinolytics were divided into two groups, according to the day of hospital admission and onset of therapy, respectively between 0 and 3 days (SG 1) and between 4 and 7 days from SAH (SG 2); treated patients (260 cases) received i.v. tranexamic acid (6 gr/day) for at least two weeks. Patients admitted before 1974, not receiving antifibrinolytics (90 cases), were selected as controls and divided into two groups (CG 1 and CG 2), according to the day of admission. In the first study group (admission 0-3 days) the rebleeding rate within 2 weeks was 9% versus 23% in controls (p less than 0.01). The incidence of rebleeding within 3 and 4 weeks was also significantly lower (p less than 0.05) than in controls. No significant difference was observed in the rebleeding rate in treated and untreated patients with late admission (4-7 days). Mortality from rebleeding was 16% in the first study group versus 17% in controls; in the second study group the figure was 6% versus 8% in controls. Seventy-five cases of ischaemic disorders (29%) were registered in treated patients versus 13 cases in controls (14%; p less than 0.01). Thirty-seven patients receiving AFT (14%) developed significant ventricular dilatation requiring shunt insertion, versus one patient in the control groups (1%; p less than 0.001). Final outcome was similar in the 4 groups. In conclusion--according to our data--AFT modifies the behaviour of rebleeding and the patients' course, although it does not modify the outcome after SAH. Clinical use of antifibrinolytic therapy appears still justified in those patients who cannot be operated on in the acute stage after SAH, provided that an associated anti-ischaemic therapy is undertaken.

Antifibrinolytic agents in subarachnoid haemorrhage

For many years clinicians have used antifibrinolytic agents to try to reduce rebleeding after subarachnoid haemorrhage. Early studies of their effectiveness produced conflicting results. This paper re-evaluates the available trials and considers benefits in the light of potential complications. Present evidence conclusively demonstrates that epsilon-aminocaproic acid and tranexamic acid administered in standard dosage, reduce the risk of rebleeding but, as a result of an increased incidence of ischaemic complications, do not benefit patients' outcome.

Determination of plasma tranexamic acid using cation-exchange high-performance liquid chromatography with fluorescence detection

A procedure is described for the determination of plasma tranexamic acid concentrations using cation exchange high-performance liquid chromatography with fluorescence detection following post-column derivatisation with omicron-phthalaldehyde. The chromatographic conditions were optimised with respect to detector performance and the method applied to measuring the plasma tranexamic acid levels of patients in a double-blind trial.

Pharmacologic management of subarachnoid hemorrhage

Subarachnoid hemorrhage, following rupture of an intracranial aneurysm, affects about 25 000 people in the U.S. each year. Less than half the patients who survive until hospital admission have an overall favorable outcome. This high morbidity and mortality rate is a result of serious complications following the initial subarachnoid hemorrhage, the most significant of these being rebleeding and cerebral ischemia secondary to vasospasm. While surgical clipping of the aneurysm is the most definitive therapy, this procedure may be postponed for a week or two after the initial hemorrhage, depending on the patient's clinical condition. Pharmacological therapy is a critical part of the preoperative care of these patients and of the postoperative management of complications. This article discusses the syndromes of rebleeding and vasospasm and reviews the current pharmacologic therapy for each.

Double-blind trial of aspirin in patient receiving tranexamic acid for subarachnoid hemorrhage

Antifibrinolytic agents have been claimed to reduce the rebleed rate in patients with subarachnoid haemorrhage from intracranial aneurysms. However, these agents may in themselves increase the incidence of delayed cerebral ischaemia in these patients. We have used aspirin in an attempt to reduce the incidence of this complication. In a prospective, double-blind trial of aspirin against placebo, 53 patients with subarachnoid haemorrhage were all treated with the antifibrinolytic agent tranexamic acid. Twenty-seven patients received aspirin and 26 patients received placebo. The morbidity and mortality was similar in each group. A further breakdown into patients who had their aneurysms clipped at craniotomy (21 patients) similarly failed to show a more favourable outcome in either group. It is concluded that aspirin does not affect the outcome in patients with subarachnoid haemorrhage treated with tranexamic acid.

Ruptured intracranial aneurysms: has the incidence of early rebleeding been over-estimated?

Of 110 consecutive patients with ruptured intracranial aneurysms, 49 underwent delayed neurological deterioration, involving 57 episodes in all. During the first three weeks after the presenting haemorrhage less than a third of these episodes were due to confirmed rebleeding. Rebleeding episodes were found to have a "flat" distribution in time during this period, but episodes of non-haemorrhagic deterioration "peaked" between days 4-12. This peak coincides with the peak for rebleeding which was described in earlier studies on aneurysms, and it is suggested that confusion between non-haemorrhagic deterioration and rebleeding may have led to a significant over-estimate of the incidence of early rebleeding with important implications for the optimum timing of surgical intervention.

Antifibrinolytic treatment in subarachnoid haemorrhage: present state

Two randomised controlled clinical trials in patients with recently ruptured intracranial aneurysms were undertaken using tranexamic acid (AMCA) to prevent early recurrent bleeding. In our accumulated series of 105 patients 53 were given AMCA and 52 were controls. 13% of the AMCA-treated patients and 31% of the controls rebled. In patients treated with AMCA the recurrent bleeding took place later than the rebleeding in the control patients. Vasospasm and delayed cerebral ischaemic deficits were seen more frequently in patients treated with AMCA. Total mortality from rebleeding and cerebral ischaemia was 25% in AMCA-treated patients and 19% in the controls during the six weeks' observation time. Coagulation factors remained unaffected by the drug. Local fibrinolysis in the cerebrospinal fluid decreased after one week in patients treated with AMCA. After two weeks the fibrinolytic activity was similar in AMCA-treated patients and in the controls. After experimental subarachnoid haemorrhage in 90 rabbits, AMCA was found to suppress plasminogen activator activity, mainly in the leptomeninges. This occurred however only during the first few postbleeding days. Antifibrinolytic agents only appear to reduce the risk of recurrent bleeding during the first ten day period after the primary aneurysm rupture. However they also seem to produce delayed cerebral ischaemia in patients with subarachnoid haemorrhage. Synthetic antifibrinolytics evidently shift the incidence of rebleeding curve to the right but these drugs are probably of diminished value in the subsequent weeks of risk.

Medical management of patients following a ruptured cerebral aneurysm, with epsilon-aminocaproic acid, kanamycin, and reserpine

Patients suffering from a subarachnoid hemorrhage who were admitted to the Neurosurgical Unit of the Royal Perth Hospital during the period 1971 to 1979 were assessed with regard to the effectiveness of preoperative treatment with epsilon-aminocaproic acid, kanamycin, and reserpine. Forty-two patients who were treated with epsilon-aminocaproic acid had a rebleed rate of 2.3% compared to 1 9.7% rebleed rate in appropriately selected controls. Patients treated with kanamycin and reserpine had a preoperative cerebral vasospasm rate of 32% compared to a 26% rate in controls; however, kanamycin and reserpine were found useful for decreasing the postoperative complications of cerebral vasospasm.

Fibrinolytic activity of cerebral tissue after experimental subarachnoid haemorrhage: inhibitory effect of tranexamic acid (AMCA)

The influence of tranexamic acid (AMCA) on the fibrinolytic activity induced by plasminogen activators (PA) of the cerebral leptomeninges, arteries and choroid plexus after artificial subarachnoid haemorrhage (SAH) was studied in 90 rabbits. SAH was induced by injection of 1-2 ml autologous blood into the suboccipital cistern. Half of the rabbits were given AMCA, 200 mg per kg body weight, in daily single i.v. injections. The rabbits were sacrificed after 3-5, 8-10 and 14-15 days respectively. Part of the leptomeninges, basilar artery and choroid plexus were removed for assaying PA by the histochemical fibrin slide and fibrin plate methods, using thiocyanate for extraction of plasminogen activator from the tissues. Quantitative assays for the fibrin plate method showed high PA in the arterial and meningeal tissues from the untreated animals 3-5 days after SAH. The PA had decreased to normal levels 8-10 days after SAH but increased again 14-15 days after SAH. A lower PA in the choroid plexus followed the same pattern. The concentration of the primary plasmin inhibitor in plasma had decreased to half of the normal value 8 days after SAH when compared to the concentration in pooled plasma from normal rabbits. In AMCA treated animals the meningeal PA, assayed by both methods, was decreased 3-5 days after SAH while no or an insignificant decrease in PA was seen 8-10 and 14-15 days after SAH. The PA of the arterial vessel wall and choroid plexus in the AMCA treated animals, assayed by the histochemical method, was moderately decreased 3-5 days after SAH, while no significant differences between untreated and AMCA treated animals were seen after 8-10 or 14-15 days when the tissues were assayed by either method. These findings indicate that AMCA suppresses PA primarily in the leptomeninges during the first few days after SAH and presumably before the meningeal fibrosis has developed.

Subarachnoid hemorrhage in middle-Finland: incidence, early prognosis and indications for neurosurgical treatment

The incidence of subarachnoid hemorrhage (SAH) in Middle-Finland 1976-78 was 19.4/100,000/year. The incidence increased consistently with age. The early prognosis was similar to that in earlier studies, with 25% dying on the first day, and 49% during the first 3 months after the initial bleeding. The fatality rate decreased sharply after the bleeding: of all deaths during the first 3 months, the weekly fatality rate was 65% during the 1st week, 12% during the 2nd, and 4% during the 3rd. Thereafter the weekly fatalities up to 3 months averaged 1.6%. Only 20% of the patients of the entire series were assessed as being eligible for neurosurgical treatment. Intercurrent fatal rebleeds further reduced this number. The chances of increasing the number of SAH patients suitable for neurosurgery are discussed. The timing of surgery should be earlier than in the present study (median 15 days after the bleeding) in order to avoid frequently fatal recurrences. Vertebral angiograms should be obtained from patients with no aneurysms found by bilateral carotid angiography. The upper age limit of 60 years should be abolished. By these means the proportion of SAH patients potentially eligible for neurosurgery could be increased to about 40%.

Determination of tranexamic acid (AMCA) and fibrin/fibrinogen degradation products in cerebrospinal fluid after aneurysmal subarachnoid haemorrhage

Six patients with recently ruptured intracranial aneurysms were treated preoperatively with tranexamic acid (AMCA). Two patients received 6 g daily in i.v. infusion, two had 6 g daily by i.v. injection, and two patients were given AMCA 9 g daily by mouth during the first week after bleeding. Serial assays of AMCA and fibrin/fibrinogen degradation products (FDP) in cerebrospinal fluid (CSF) were performed during 6--13 days after the initial subarachnoid haemorrhage (SAH). Judged from the decline in CSF-FDP, an assumed therapeutic level of greater than or equal to 1 mg/l of AMCA in CSF was reached within 24--36 hours after the first dose when the drug was administered intravenously and within 48 hours when the drug was given orally.

Anti-fibrinolytic treatment in the pre-operative management of subarachnoid haemorrhage caused by ruptured intracranial aneurysm

One hundred consecutive patients treated with epsilon aminocaproic acid 24 grams daily prior to surgery for ruptured intracranial aneurysms have been compared with the previous 100 patients managed similarly but without anti-fibrinolytic drugs. No other alterations in management were made and the two series are closely comparable in all other respects. Fewer episodes of recurrent haemorrhage and deaths from this cause occurred in the treated patients, but more cases of cerebral ischaemia occurred. Neither difference is statistically significant and overall more deaths occurred in the patients treated with antifibrinolytic drugs. The value of this method of treatment in the management of aneurysmal subarachnoid haemorrhage is questioned.

Effect of antifibrinolytic therapy on subarachnoid fibrosis in dogs after experimental subarachnoid haemorrhage

The effect of antifibrinolytic therapy on posthaemorrhagic subarachnoid fibrosis was observed experimentally in dogs with the scanning electron microscope (SEM). The subchronic subjects, given intravenous injections of tranexamic acid (1 mg/day) for 12 days and sacrificed 3 weeks after cisternal blood injection, showed residual clot with thick fibrosis, especially around the haemorrhage. The chronic subjects, to which the same procedure was applied and which were sacrificed three months after cisternal blood injection, showed significant increases in the subarachnoid fibrosis, most remarkably in the parasagittal region. Tranexamic acid is widely used for preventing the recurrence of subarachnoid haemorrhage. However, it was revealed in this study that antifibrinolytic therapy might increase chronic posthaemorrhagic subarachnoid fibrosis, which is considered to be responsible for communicating hydrocephalus by disturbing epicortical CSF flow.