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Liu T, Wu L, Xue R, Ding H. Efficacy and safety of tranexamic acid in aneurysmal subarachnoid hemorrhage: A meta-analysis of randomized controlled trials. Am J Emerg Med 2021; 50:646-653. [PMID: 34879481 DOI: 10.1016/j.ajem.2021.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Tranexamic acid, as a traditional hemostatic agent, is commonly used to treat or prevent excessive blood loss. However, the role of tranexamic acid in promoting good clinical outcomes and reducing mortality and risk of adverse events during the treatment of aneurysmal subarachnoid hemorrhage remains unclear. METHODS In strict accordance with the inclusion and exclusion criteria, Cochrane Library, Embase, Web of Science, and PubMed databases were assessed for randomized controlled trials (published between 1980 and 2021). Data were analyzed using STATA 16.0 and RevMan 5.3. In addition, the fixed-effects model (M-H method) and effect size (risk difference; RD) were used as a pooled measure to combine data. We also performed a post hoc sensitivity analysis and subgroup analysis to evaluate each outcome with low heterogeneity. RESULTS A meta-analysis revealed that although tranexamic acid was related to less rebleeding (RD = -0.06; 95% CI [-0.09, -0.03]; P = 0.0006), there is evidence that it has no an effect on good clinical outcomes or mortality (RD = -0.01; 95% CI [-0.05, 0.02]; P = 0.51; RD = 0.00; 95% CI [-0.03, 0.04]; P = 0.91). Tranexamic acid was associated with increased hydrocephalus (RD = 0.04; 95% CI [0.01, 0.08]; P = 0.02) and seizure (RD = 0.04; 95% CI [0.00, 0.08]; P = 0.05). The incidence of thromboembolic complications or delayed cerebral ischemia was not different in the two groups (RD = -0.01; 95% CI [-0.04, 0.03]; P = 0.62; RD = 0.00; 95% CI [-0.03, 0.03]; P = 0.96), and significant drug-related overall adverse events were identified (RD = 0.02; 95% CI [0.00, 0.04]; P = 0.03). CONCLUSIONS These findings indicate that the routine use of tranexamic acid is not suggested for patients with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Tao Liu
- Department of Neurosurgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, China.
| | - Lingqin Wu
- Zhoushan Women and Children Hospital, Zhoushan 330902, China
| | - Renmin Xue
- Department of Cell Biology, Capital Medical University, Beijing 100069, China
| | - Huiru Ding
- Department of Endocrinology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Buell TJ, Ding D, Raper DMS, Chen CJ, Hixson HR, Crowley RW, Evans AJ, Jensen ME, Liu KC. Posterior circulation perforator aneurysms: a proposed management algorithm. J Neurointerv Surg 2017; 10:55-59. [PMID: 28062803 DOI: 10.1136/neurintsurg-2016-012891] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Subarachnoid hemorrhage (SAH) from posterior circulation perforator aneurysms (PCPAs) is rare and its natural history is unknown. Diagnosis may be difficult, acute management is poorly defined, and long-term recurrent SAH rates and clinical outcome data are lacking. METHODS We searched our institution's records for cases of PCPA rupture and analyzed patient demographics, Hunt and Hess (HH) grades, diagnostic imaging, management, and clinical outcomes. We conducted telephone interviews to calculate modified Rankin Scale (mRS) scores. RESULTS We identified 9 patients (6 male, 3 female) with a ruptured PCPA who presented to the University of Virginia Health System (Charlottesville, VA, USA) between 2010 and 2016. Median and mean ages were 62 and 63 years, respectively. Median HH grade was 3. Seven of nine (78%) PCPAs were angiographically occult on initial imaging and median time to diagnosis was 5 days. Three conservatively managed patients had a mean mRS score of 0.67 (range 0-1) at mean follow-up of 35.3 months. Antifibrinolytic therapy was administered to all conservatively managed patients without thrombotic complication. Six patients receiving endovascular treatment had a mean mRS score of 2.67 (range 0-6) at mean follow-up of 49.2 months. No cases of recurrent SAH were seen in the study. CONCLUSIONS The rarity of PCPA has precluded long-term clinical follow-up until now. Our experience suggests low recurrent SAH rates. Until further studies are performed, conservative management, possibly combined with antifibrinolytic therapy, may be a viable treatment with acceptable long-term outcome.
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Affiliation(s)
- Thomas J Buell
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Daniel M S Raper
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Harry R Hixson
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - R Webster Crowley
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Avery J Evans
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mary E Jensen
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA.,Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
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Bederson JB, Connolly ES, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE, Harbaugh RE, Patel AB, Rosenwasser RH. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009; 40:994-1025. [PMID: 19164800 DOI: 10.1161/strokeaha.108.191395] [Citation(s) in RCA: 911] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Antifibrinolytic Therapy To Prevent Early Rebleeding After Subarachnoid Hemorrhage. Neurocrit Care 2008; 8:418-26. [DOI: 10.1007/s12028-008-9088-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Proust F, Ter Minassian A, Hans P, Puybasset L, Berré J, Bonafé A, Dufour H, Audibert G, De Kersaint-Gilly A, Boulard G, Beydon L, Ravussin P, Lejeune JP, Gabrillargues J, Bruder N. [Treatment of intracranial hypertension in patients suffering from severe subarachnoid haemorrhage]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:729-33. [PMID: 15967626 DOI: 10.1016/j.annfar.2005.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Affiliation(s)
- F Proust
- Service de neurochirurgie, CHU de Rouen, hôpital Charles-Nicolle, avenue de Germont, 76031 Rouen cedex, France.
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Cheong JJY, Ghinea N, van Gelder JM. Estimating the annual rate of de novo multiple aneurysms: three statistical approaches. Neurosurg Focus 2004; 17:E8. [PMID: 15633985 DOI: 10.3171/foc.2004.17.5.8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Individuals with unruptured intracranial aneurysms experience a higher rate of rupture if their history includes another aneurysm that has previously bled. The authors used systematic review and metaregression to estimate the annual rate of development of second de novo aneurysms after subarachnoid hemorrhage.
Methods
This investigation included studies in which more than 300 patients with intracranial aneurysms were described, and in which the age of the patients and the proportion with multiple aneurysms were documented. Studies describing delayed follow-up angiography that was performed after treatment of aneurysms were also reviewed.
Twenty studies were included in a between-study analysis. The univariate odds ratio (OR) for multiple intracranial aneurysms per year of age was 1.085 (95% confidence interval [CI] 1.015–1.165); this value was calculated using a hierarchical model for between-study heterogeneity. Five studies were included that provided age stratification. The estimated OR for multiple intracranial aneurysms per year was 1.011 (95% CI 1.005–1.018). Four follow-up studies were available.
Conclusions
According to the three different approaches (study-level, patient-level, and follow-up analyses), the estimated annual rates of development of de novo aneurysms were 1.62% (95% CI 0.28–3.59%), 0.28% (95% CI 0.12–0.49%), and 0.92% (95% CI 0.64–1.25%), respectively. The estimated annual rate of development of second de novo aneurysms ranged from 0.28 to 1.62%.
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Affiliation(s)
- James Ju Yong Cheong
- Department of Neurosurgery, South Western Sydney Area Health Service, University of New South Wales, Sydney, Australia
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Vates GE, Zabramski JM, Spetzler RF, Lawton MT. Intracranial Aneurysms. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley EC, Heros RC, Sternau LL, Torner J, Adams HP, Feinberg W. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1994; 90:2592-605. [PMID: 7955232 DOI: 10.1161/01.cir.90.5.2592] [Citation(s) in RCA: 157] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M R Mayberg
- Office of Scientific Affairs, American Heart Association, Dallas, TX 75231-4596
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Rinne J, Hernesniemi J, Puranen M, Saari T. Multiple intracranial aneurysms in a defined population: prospective angiographic and clinical study. Neurosurgery 1994; 35:803-8. [PMID: 7838326 DOI: 10.1227/00006123-199411000-00001] [Citation(s) in RCA: 126] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Multiple intracranial aneurysms (MIA) have been detected in up to one-third of patients with cerebral aneurysms. Three main external factors influence these figures as follows: the quality of angiographies, the quantity of vessels studied, and referral policy. In a 1-year prospective study, we determined the incidence of MIA in a defined catchment area in East Finland by investigating all of the patients with intracranial aneurysms with panangiography. In 114 unselected patients, a total of 170 intracranial aneurysms were detected, and, of these, 39 (34%) harbored MIA. In contrast to most other reports, there was a male predominance in patients with MIA, and half of these men had hypertension. Intracavernous carotid and pericallosal aneurysms were more frequent in patients with MIA. The number of asymptomatic vertebrobasilar aneurysms was extremely low, and most of the nonruptured aneurysms were found in bilateral carotid angiograms. In spite of the active search, the proportion of vertebrobasilar aneurysms remained at 6%. Although our surgical policy was most active, one-third of the asymptomatic aneurysms remained untreated, mainly because of the poor condition of the patient.
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Affiliation(s)
- J Rinne
- Department of Neurosurgery, University Hospital of Kuopio, Finland
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Mayberg MR, Batjer HH, Dacey R, Diringer M, Haley EC, Heros RC, Sternau LL, Torner J, Adams HP, Feinberg W. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994; 25:2315-28. [PMID: 7974568 DOI: 10.1161/01.str.25.11.2315] [Citation(s) in RCA: 273] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M R Mayberg
- Office of Scientific Affairs, American Heart Association, Dallas, TX 75231-4596
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Steiger HJ, Fritschi J, Seiler RW. Current pattern of in-hospital aneurysmal rebleeds. Analysis of a series treated with individually timed surgery and intravenous nimodipine. Acta Neurochir (Wien) 1994; 127:21-6. [PMID: 7942176 DOI: 10.1007/bf01808541] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The management of aneurysmal subarachnoid haemorrhage has recently changed considerably. Emergency admission to specialized centres and early surgery have become common practice. In addition, the use of nimodipine has gained widespread acceptance. Little data are available concerning the frequency and temporal profile of reruptures under the current policies. The case histories of 387 patients treated for aneurysmal subarachnoid haemorrhage between January 1984 and March 1992 were reviewed with regard to the incidence of in-hospital reruptures. All patients were managed according to the same protocol including a policy of individually timed early surgery and intravenous nimodipine. A total of 44 first in-hospital rebleeds were observed during the waiting period. Two percent of the patients admitted on the day of haemorrhage had a rebleed on the same day after admission to the hospital. No rebleeds were observed on the day after subarachnoid haemorrhage. Rebleed rates on day 2 and 3 were also low with 0.6 and 0.8% of the population with an unclipped aneurysm. For the following 10 days, the daily rate of rerupture increased. A further peak was observed during the 4th week. Using life-table methods, the cumulative rate of rebleeds was calculated as 23% within 2 weeks and 42% within 4 weeks. Although patients suffering rebleeds differed in several respects from patients without rebleeds, most of the differences could be identified to be a consequence of a selection bias resulting in a longer period of exposure to the risk of rerupture for certain subgroups. Only patients suffering a loss of consciousness after the initial subarachnoid haemorrhage were definitively exposed to a higher daily risk of rerupture.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H J Steiger
- Department of Neurosurgery, Inselspital, Bern, Switzerland
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Abstract
OBJECTIVE To assess the current status and future directions of therapy in cerebrovascular disease. DATA SOURCES English language literature search using MEDLINE, Index Medicus, reviews, texts and relevant papers. STUDY SELECTION Information has been drawn from approximately 200 articles. DATA EXTRACTION AND SYNTHESIS Those articles with most relevance to current practice and future directions in the therapy of cerebrovascular disease have been cited. CONCLUSIONS Much progress has been made over the last 30 years in the therapy of primary and secondary prevention of cerebrovascular disease. The introduction of antihypertensive agents has been largely responsible for the decline in mortality from stroke and, in some areas, the incidence. Anticoagulants such as warfarin protect against ischaemic stroke in patients with mitral or aortic valve disease and/or atrial fibrillation. Antiplatelet agents are clearly effective in the secondary prevention of ischaemic stroke after transient ischaemic attacks; the risk of stroke or death is reduced, on average, by 22%. In patients with subarachnoid haemorrhage, ischaemic complications caused by vasospasm are reduced by calcium channel blockers. A new wave of therapies is now on the horizon to minimise tissue damage in the early stages of ischaemic stroke ("tissue rescue") with the introduction of thrombolytic agents, calcium channel blockers, NMDA antagonists and haemodilution techniques and many of these are currently being subjected to clinical trial. If they prove to be effective, our current management of acute ischaemic stroke may alter dramatically.
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Affiliation(s)
- G A Donnan
- Department of Neurology, Austin Hospital, Heidelberg, VIC
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