Intracranial aneurysms and subarachnoid hemorrhage. A cooperative study. Antifibrinolytic therapy in recent onset subarachnoid hemorrhage

Validation of the accuracy of the modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading scale for predicting the outcomes of patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Evaluating the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) who may be at risk of poor outcomes using grading systems is one way to make a better decision on treatment for these patients. This study aimed to compare the accuracy of the modified World Federation of Neurosurgical Societies (WFNS), WFNS, and Hunt and Hess (H&H) Grading Scales in predicting the outcomes of patients with aSAH.

METHODS

From August 2019 to June 2021, we conducted a multicenter prospective cohort study on adult patients with aSAH in three central hospitals in Hanoi, Vietnam. The primary outcome was the 90-day poor outcome, measured by a score of 4 (moderately severe disability) to 6 (death) on the modified Rankin Scale (mRS). We calculated the areas under the receiver operator characteristic (ROC) curve (AUROCs) to determine how well the grading scales could predict patient prognosis upon admission. We also used ROC curve analysis to find the best cut-off value for each scale. We compared AUROCs using Z-statistics and compared 90-day mean mRS scores among intergrades using the pairwise multiple-comparison test. Finally, we used logistic regression to identify factors associated with the 90-day poor outcome.

RESULTS

Of 415 patients, 32% had a 90-day poor outcome. The modified WFNS (AUROC: 0.839 [95% confidence interval, CI: 0.795-0.883]; cut-off value≥2.50; PAUROC<0.001), WFNS (AUROC: 0.837 [95% CI: 0.793-0.881]; cut-off value≥3.5; PAUROC<0.001), and H&H scales (AUROC: 0.836 [95% CI: 0.791-0.881]; cut-off value≥3.5; PAUROC<0.001) were all good at predicting patient prognosis on day 90th after ictus. However, there were no significant differences between the AUROCs of these scales. Only grades IV and V of the modified WFNS (3.75 [standard deviation, SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), WFNS (3.75 [SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), and H&H scales (2.96 [SD: 2.60] vs 4.97 [SD: 1.87], p<0.001, respectively) showed a significant difference in the 90-day mean mRS scores. In multivariable models, with the same set of confounding variables, the modified WFNS grade of III to V (adjusted odds ratio, AOR: 9.090; 95% CI: 3.494-23.648; P<0.001) was more strongly associated with the increased risk of the 90-day poor outcome compared to the WFNS grade of IV to V (AOR: 6.383; 95% CI: 2.661-15.310; P<0.001) or the H&H grade of IV to V (AOR: 6.146; 95% CI: 2.584-14.620; P<0.001).

CONCLUSIONS

In this study, the modified WFNS, WFNS, and H&H scales all had good discriminatory abilities for the prognosis of patients with aSAH. Because of the better effect size in predicting poor outcomes, the modified WFNS scale seems preferable to the WFNS and H&H scales.

Predictors of aneurysmal rebleed before definitive surgical or endovascular management

BACKGROUND

Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers.

METHOD

A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis.

RESULTS

Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p = 0.023), diastolic blood pressure of >90 mmHg on admission (p = 0.008); presence of loss of consciousness (p = 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p = 0.005); higher Fisher grade (p < 0.001); presence of multiple aneurysms (p = 0.021); irregular aneurysm surface (0.002).

CONCLUSIONS

Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.

Risk Factors for Re-bleeding of Aneurysmal Subarachnoid Hemorrhage: Systemic Review and Meta Analysis

Objective : The mortality of re-bleeding is high and patients surviving are usually in poor clinical condition and have a worse outcome than patients with single bleed. We performed an update systemic review and Meta-analysis to determine the most common risk factors for re-bleeding in aneurysmal subarachnoid hemorrhage patients.

Method: We reviewed all publications on the risk factors of the re-bleeding or rerupture of already bled intracranial aneurysms. This Meta analysis included studies published from the year 2000 until 2013. Pooled mean difference was calculated for the continuous variables (Age), and pooled odds ratio (OR) was calculated for categorical factors. Heterogeneity was tested first. If it is significant (p<0.05), random effect model was applied, otherwise, fixed model was used. Software - Review manager was used to find pooled effects and perform significant test for each potential risk factor.

Results : We identified 174 articles. Only 7 retrospective studies had met the inclusion criteria, with 2470 patients, 283 patients had aneurysmal re-bleeding. The weighted average rate of re-bleeding is 11.3% with 95% confidence interval [CI]: 10.1-12.6. Statistically significant risk factor for re-bleeding were sex (OR 1.46; 95% CI: 1.11, 1.92), high systolic blood pressure [SBP] (OR 2.52; 95% CI: 1.40, 4.53), aneurysm size (OR 3.00; 95% CI: 2.06- 4.37), clinical condition (Hunt & Hess) (OR 4.94; 95% CI: 2.29, 10.68), and Fisher Grade (OR 2.29; 95% CI: 1.45, 3.61).

Conclusion: Sex, high SBP, high Fisher Grade, aneurysm size larger than 10 mm, and patients with poor clinical condition (Hunt & Hess) were independent risk factors for aneurysmal re-bleeding. The importance of early aneurysm intervention should be emphasized to eliminate the risk of re-bleeding and poor outcome.

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.

Evidence-based pharmacotherapy for cerebral vasospasm

INTRODUCTION

The vast amount of literature on the pharmaceutical treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage remains daunting. Optimal treatment regimens for patients can be obscured by studies not statistically powered to draw evidenced-based conclusions.

METHODS

In this chapter, we reviewed the English literature using the National Library of Medicine for studies regarding pharmacotherapies for the treatment of cerebral vasospasm. These studies were then categorized according to the US Preventative Services Task Force ranking system for evidence based medicine and reviewed each pharmacotherapy for its efficacy in the treatment of cerebral vasospasm.

RESULTS

Nimodipine (Nimotop), HMG Co-A reductase inhibitor (statins) and enoxaparin (Lovenox) were the only drugs with level-1 evidence available for the treatment of vasospasm from aneurysmal subarachnoid hemorrhage as defined by the US Preventative Services Task Force.

CONCLUSION

As the understanding of the pathophysiological mechanisms of vasospasm after aneurysmal subarachnoid hemorrhage evolves in the basic science laboratory, novel medications are being trialed in humans. However, significantly more work must be carried out in this area before we have an effective medical treatment that can prevent or reverse the devastating events of cerebral vasospasm.

CONTROVERSIES IN THE SURGICAL TREATMENT OF RUPTURED INTRACRANIAL ANEURYSMS

THE MANAGEMENT OF aneurysmal subarachnoid hemorrhage has evolved over time, including the use of the microscope for aneurysm clip application, improved imaging modalities, endovascular methods for aneurysm treatment, dedicated neurointensive care units, and more aggressive therapy for cerebral vasospasm. Although these advancements have reduced the morbidity and mortality associated with aneurysmal subarachnoid hemorrhage, outcomes for this patient population continue to leave much room for improvement. This work highlights controversial adjuvant techniques, maneuvers, and therapies surrounding the surgical treatment of ruptured cerebral aneurysms that currently lack a consensus opinion. These treatments include centralized care in high-volume centers, as well as the use of antifibrinolytic therapy, routine cerebrospinal fluid diversion, intraoperative hypothermia, temporary clip application, neuroprotective drugs, intraoperative angiography, and decompressive hemicraniectomy. Although definitive answers will only be possible through future multicenter collaboration, we review the controversy surrounding these adjuncts and report the consensus opinion from a highly experienced audience.

Detecting and treating microvascular ischemia after subarachnoid hemorrhage

PURPOSE OF REVIEW

To provide an overview of the current management of cerebral vasospasm following subarachnoid hemorrhage, emphasizing the detection and treatment of delayed ischemia.

RECENT FINDINGS

Sensitive and specific monitoring methods are necessary to register the onset of cerebral vasospasm early to prevent long-term morbidity and mortality. Therefore, various techniques to measure cerebral perfusion and/or surrogate parameters have been developed. Prophylaxis with calcium antagonists such as nimodipine is administered for neuroprotection. Resolution of ongoing cerebral vasospasm can be achieved by either dilating constricted vessels or optimizing hemodynamics. Therapeutic treatment with hypertension, hypervolemia and hemodilution (HHH) has a direct influence on cerebral vasospasm, ischemic sequelae and outcome, while prophylactic HHH leads to excess complications. Other treatments, for example endothelin antagonists, statins or magnesium salts, used to prevent or treat cerebral vasospasm, are being tested. Endovascular treatment options can be used for therapy-refractory cerebral vasospasm, but they carry procedure-related risks and may be short-acting.

SUMMARY

Diagnosis of microvascular ischemia following subarachnoid hemorrhage involves clinical observation, non-invasive determination of cerebral hemodynamic variables, autoregulation studies and invasive online monitoring of cerebral oxygenation and metabolism. Nimodipine is administered prophylactically, while HHH is initiated therapeutically. New causal therapies are being evaluated.

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.

Clinical outcomes of aneurysmal subarachnoid hemorrhage patients treated with oral diltiazem and limited intensive care management

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) patients are frequently treated with prophylactic nimodipine and undergo invasive monitoring of blood pressure and volume status in an intensive care unit (ICU) setting to decrease the incidence of delayed ischemic neurological deficit (DIND) and improve functional outcomes. The goal of this study was to examine the incidence of DIND and poor functional outcomes in a consecutive series of SAH patients treated with a different regimen of prophylactic oral diltiazem and limited use of intensive care monitoring.

METHODS

The study involved a consecutive series of 123 aneurysmal SAH patients treated by the senior author who were admitted within 72 hours of hemorrhage and who never received nimodipine or nicardipine. Functional outcomes were graded using the Glasgow Outcome Scale (GOS).

RESULTS

Of the 123 patients identified, favorable outcomes (GOS 4 and 5) were achieved in 74.8%. The incidence of DIND was 19.5%. Hypertensive, hypervolemic, hemodilutional (HHH) therapy was used in 10 patients (8.1%) and no patients were treated for DIND by endovascular means. Seven patients (5.7%) had a poor functional outcome or death because of DIND and two of these were related to complications of HHH therapy. These results were compared to contemporary series of SAH patients managed with other treatment protocols.

CONCLUSIONS

Functional outcomes of patients treated with a regimen of oral diltiazem, limited use of ICU monitoring and HHH therapy for DIND compare favorably with other contemporary series of SAH patients.

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.

How should a subarachnoid hemorrhage grading scale be determined? A combinatorial approach based solely on the Glasgow Coma Scale

OBJECT

The purpose of this study was to present a combinatorial approach used to develop a subarachnoid hemorrhage (SAH) grading scale based on the patient's preoperative Glasgow Coma Scale (GCS) score.

METHODS

There are 4094 different combinations that can be used to compress the 13 scores of the GCS into two to 12 grades. Break points, the positions in the scale in which two adjacent scores connote a significantly different outcome, are obtained by a direct comparison of the GCS and the Glasgow Outcome Scale (GOS). Guided by the break points, the number of combinations to be considered can be limited. All possible combinations are statistically analyzed with respect to intergrade differences in outcome. Single combinations, with the maximum number of grades having maximum intergrade outcome differences for each corresponding set of adjacent grades, must be selected. The authors verified the validity of this combinatorial approach by retrospectively analyzing 1398 consecutive patients with aneurysmal SAH who underwent surgery within 7 days of the last hemorrhage episode. The patients' GCS scores were assessed just before surgery and their GOS scores were estimated 6 months post-SAH. The combinatorial approach yields only one acceptable grading scale: I (GCS Score 15); II (GCS Scores 11-14); III (GCS Scores 8-10); IV (GCS Scores 4-7); and V (GCS Score 3).

CONCLUSIONS

The combinatorial approach, guided by the break points, is so simple and systematic that it can be used again in the future when revision of the grading scale becomes necessary after development of new and effective treatment modalities that improve patients' overall outcome.

Rebleeding during transport of patients with a ruptured intracranial aneurysm

Although many reports have described the rebleeding risk of the ruptured aneurysm in already hospitalized patients, there are only a few reports that have addressed the incidence of rebleeding in these patients before hospitalization. To improve the prognosis of patients with a ruptured intracranial aneurysm, it seems very important to know the incidence of rebleeding before hospitalization. We focused on changes in the computed tomographic (CT) scans and neurological findings at the primary hospital and our institution in 366 patients with ruptured aneurysms who were transferred on the day of the initial hemorrhage, and studied the rebleeding rates in these patients. In 73 (19.9%), we confirmed that rebleeding from the ruptured aneurysm had occurred during transport. The incidence of rebleeding in the prehospitalized patients with a ruptured aneurysm is supposed to by very high. Appropriate medical countermeasures for prevention of rebleeding in prehospitalized patients are crucial to decrease the overall mortality and morbidity rate of intracranial aneurysm.

Incidence of cerebral vasospasm after endovascular treatment of acutely ruptured aneurysms: report on 69 cases

Cerebral vasospasm is the most common cause of morbidity and mortality in patients admitted to the hospital after suffering aneurysmal subarachnoid hemorrhage (SAH). The early surgical removal of subarachnoid clots and irrigation of the basal cisterns have been reported to reduce the incidence of vasospasm. In contrast to surgery, the endovascular treatment of aneurysms does not allow removal of subarachnoid clots. In this study the authors measured the incidence of symptomatic vasospasm after early endovascular treatment of acutely ruptured aneurysms with Guglielmi detachable coils (GDCs). Sixty-nine patients classified as Hunt and Hess Grades I to III underwent occlusion of intracranial aneurysms via GDCs within 72 hours of rupture. The amount of blood on the initial computerized tomography (CT) scan was classified by means of Fisher's scale. Symptomatic vasospasm was defined as the onset of neurological deterioration verified with angiographic or transcranial Doppler studies. Hypertensive, hypervolemic, hemodilution therapy, with or without intracranial angioplasty, was used to treat vasospasm after GDC placement. Symptomatic vasospasm occurred in 16 (23%) of 69 patients. The clinical grade at admission and the amount of blood on the initial CT were both associated with the incidence of subsequent vasospasm. At 6-month clinical follow-up examination, 12 of these 16 patients experienced a good recovery, two were moderately disabled, and two patients had died of vasospasm. In conclusion, the 23% incidence of symptomatic vasospasm in this series compares favorably with that found in conventional surgical series of patients with acute aneurysmal SAH. These results indicate that endovascular therapy does not have an unfavorable impact on cerebral vasospasm.

Effect of transluminal angioplasty on cerebral blood flow in the management of symptomatic vasospasm following aneurysmal subarachnoid hemorrhage

In this study the authors have examined the effects of transluminal angioplasty on cerebral blood flow (CBF) in the management of intractable vasospasm following aneurysmal subarachnoid hemorrhage (SAH). Fourteen consecutively enrolled patients underwent attempted angioplasty with or without intraarterial infusion of papaverine. Twelve patients underwent pre- and postangioplasty xenon-enhanced computerized tomography (Xe-CT) scanning to measure regional CBF in 55 to 65 regions of interest (ROIs) per patient. Angioplasty was possible in 13 (93%) of 14 patients, with angiographically demonstrated improvement in all 13. Twelve (92%) of the 13 patients were neurologically improved following angioplasty; seven (58%) of the 12 patients who improved had a complete reversal of all delayed ischemic deficits. Angioplasty significantly decreased the mean number of ROIs at risk (11.4 ROIs pre- and 0.9 ROIs postangioplasty) (p < 0.00005, t-test). All patients had a reduction in the number of ROIs at risk after angioplasty; six (50%) of 12 no longer had any ROIs remaining at risk after angioplasty. Angioplasty significantly increased the mean CBF within at-risk ROIs (13 ml/100 g/minute pre- and 44 ml/100 g/minute postangioplasty) (p < 0.00005, t-test). All patients experienced an improvement in mean CBF in at-risk ROIs after angioplasty, with the mean CBF improving to above 20 ml/100 g/minute in all cases. No differences in the degree of improvement were found in patients who received intraarterial papaverine compared with those who did not. In the majority of patients with refractory vasospasm following SAH, angioplasty effectively dilated spastic arteries, reversed delayed neurological deficits, and significantly improved CBF in areas of brain at risk of infarction.

Reducing the risk of rebleeding before early aneurysm surgery: a possible role for antifibrinolytic therapy

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.

Rhabdomyolysis induced by epsilon-aminocaproic acid

OBJECTIVE

To report a case of rhabdomyolysis associated with epsilon-aminocaproic acid (epsilon-ACA).

CASE SUMMARY

A 33-year-old female patient with chronic granulocytic leukemia was treated with epsilon-ACA for approximately 3.5 months for thrombocytopenic bleeding. The initial dosage was 4 g po q6h. One month after an increase in dosage to 5 g po 14h the patient developed severe lower extremity myalgia and marked weakness. Laboratory investigations revealed an elevated creatine kinase (CK), lactate dehydrogenase (LDH). aspartate aminotransferase (AST), and myoglobinemia. Epsilon-ACA was thought to be the causative agent and was discontinued. The patient received intravenous fluids to minimize renal damage due to myoglobin. Serum enzyme concentrations did not return to normal. The patient died of a central nervous system hemorrhage 1 week after the epsilon-ACA was discontinued.

DISCUSSION

There were 31 cases of epsilon-ACA-induced myopathies published in the literature (MEDLINE) from 1972 to June 1995. Of these, 10 cases were reviewed. In all cases, patients received epsilon-ACA in doses ranging from 16 to 36 g/d for more than 28 days. Clinical findings varied from extreme muscle weakness to myopathic changes in electromyelograms. All patients recovered following discontinuation of epsilon-ACA.

CONCLUSIONS

Long-term therapy with high-dose epsilon-ACA may produce muscle weakness or rhabdomyolysis. Patients who require long-term, high-dose epsilon-ACA therapy should be monitored for myoglobinuria and changes in serum CK, LDH, and AST, for myoglobinemia, for decreases in muscle strength, and/or for myalgia. Significant changes in these parameters compared with baseline values should suggest a need to discontinue epsilon-ACA therapy.

Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study

OBJECTIVES

This report examines the frequency, type, and prognostic factors of medical (nonneurologic) complications after subarachnoid hemorrhage in a large, prospective study. The influences of contemporary neurosurgical, neurological, and critical care practice on mortality and morbidity rates after aneurysmal subarachnoid hemorrhage are evaluated.

DESIGN

A study of medical complications observed in the placebo limb of a large, randomized, controlled trial of the calcium antagonist, nicardipine, after subarachnoid hemorrhage.

SETTING

Patients were recruited from 50 hospitals in 41 neurosurgical centers in the United States and Canada.

PATIENTS

A total of 457 patients with subarachnoid hemorrhage, > or = 18 yrs of age, were randomly assigned to the placebo group. All patients arrived at the participating center within 7 days (mean 1.0 +/- 1.8 [SD] days) of rupture of an angiographically documented saccular aneurysm.

MEASUREMENTS AND MAIN RESULTS

The frequency rates of symptomatic vasospasm, rebleeding, and total mortality rate after subarachnoid hemorrhage at 3-month follow-up were 46%, 7%, and 19%, respectively. The frequency of having at least one severe (life-threatening) medical complication was 40%. The proportion of deaths from medical complications was 23%. This value was comparable with the proportion of deaths attributed to the direct effects of the initial hemorrhage (19%), rebleeding (22%), and vasospasm (23%) after aneurysmal rupture. The frequency of life-threatening cardiac arrhythmias was 5%; less ominous rhythm disturbances occurred in 30% of the patients. There was an increased frequency of cardiac arrhythmias on the day of, or day after, aneurysm surgery. Pulmonary edema occurred in 23% of the patients, with a 6% occurrence rate incidence of severe pulmonary edema. There was a wide variation from center to center, with the greatest frequency on days 3 through 7. There was a nonsignificant association of pulmonary edema with the use of hypertensive hypervolemic therapy (p = .10), and a significant association with the timing of surgery (p < .05). Some degree of hepatic dysfunction was noted in 24% of patients, the majority with only mild abnormalities of hepatic enzymes with no clinical accompaniment (4% frequency of severe hepatic dysfunction). Thrombocytopenia occurred in 4% of patients, usually in the setting of sepsis. Renal dysfunction was reported in 7% of the patients, with 15% of that figure deemed to be of life-threatening severity. There was an association (p = .001) with antibiotic therapy.

CONCLUSIONS

Potentially preventable medical complications after ruptured cerebral aneurysm add to the total mortality rate of patients, and may increase length of hospital stay in the critical care setting. The proportion of deaths after subarachnoid hemorrhage from medical complications equals those deaths from either direct effects, rebleeding, or vasospasm individually. Pulmonary complications are the most common nonneurologic cause of death. Cardiac arrhythmia, although frequent, was not associated with significant mortality. The frequency of cardiac arrhythmia and pulmonary edema increased on the day of, or day after, aneurysm surgery. Renal and hepatic dysfunction, and blood dyscrasias, were also observed, underscoring the need for meticulous monitoring for metabolic and hematologic derangements.

Early surgery for posterior circulation aneurysms following subarachnoid haemorrhage

A retrospective analysis of 32 patients with posterior circulation aneurysms operated on within three days of subarachnoid haemorrhage is presented. The cases were treated at two Australian neurosurgery units over a five year period (1988-1992), both units having a policy of treating patients of all grades and all ages with early surgery. No patients suffered rebleeding. Five patients developed clinical vasopasm. Twenty-four patients (75%) had a good outcome (Glasgow Outcome Score 1-2), three had a poor outcome (GOS 3), and five died (16%). Of the five deaths, three presented as Hunt and Hess grade V. The results are considered in detail and the literature regarding the timing of surgery for posterior circulation aneurysms is reviewed.

Does thrombin prevent cerebral vasospasm following aneurysmal subarachnoid haemorrhage?

Fibrinopeptide A (FPA) levels which have been shown to be a quantitative index of thrombin generation, were measured in blood and cerebrospinal fluid (CSF) samples from patients following subarachnoid haemorrhage (SAH) and from a control population. The levels found in samples obtained in patients following SAH are compared with those found in controls and also correlated with clinical grade on admission as assessed by the Glasgow Coma Score and the World Federation of Neurological Surgeons' grading system, and with the amount of subarachnoid blood seen on CT, the occurrence of ischaemic deterioration, the occurrence of low-density change on CT, the presence of vasospasm on angiography, clinical outcome as assessed by the Glasgow Outcome Score 3 months following the ictus, and the incidence of ischaemia as a cause of death or disability as assessed 3 months following the ictus. The levels of FPA found in blood and CSF from patients following SAH were significantly raised when compared with those found in controls. There was significant correlation between blood FPA levels and the amount of subarachnoid blood seen on initial CT. CSF FPA levels had a statistically significant correlation with outcome as assessed at 3 months post-ictus. No statistically significant correlation was found between blood or CSF FPA levels and any of the other variables studied.

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).

The effects of treating hypertension following aneurysmal subarachnoid hemorrhage

We investigated in a consecutive series of 134 patients with aneurysmal subarachnoid hemorrhage whether institution of antihypertensive treatment was related to the incidence of cerebral ischemia and rebleeding. The aim of hypertensive treatment was to reduce the diastolic blood pressure to levels below 100 mm Hg. There was no difference in outcome between patients with or without antihypertensive drugs. Rebleeding was less frequent in patients with antihypertensive treatment (12/80 patients (15%) versus 18/54 patients (33%) without anti-hypertensive treatment (p = 0.012)). Nevertheless, patients with anti-hypertensive treatment had, on average, still higher blood pressures than untreated patients. Conversely, infarction occurred more often in patients with anti-hypertensive treatment (34/80 patients (43%) versus 12/54 (22%) without antihypertensives (p = 0.03)). This relationship was partly explained by co-existing hyponatremia. Our results suggest that the need for antihypertensive treatment is questionable, since the prevention of rebleeding is offset by an increased risk of cerebral infarction.

Convulsions induced by aminocaproic acid infusion

Aminocaproic acid is a widely used antifibrinolytic agent. Serious adverse effects associated with its use are rare, but we report on a patient with liver disease and cirrhosis who experienced a grand mal seizure during the intravenous administration of aminocaproic acid. Clinicians should be alert to the occurrence of this adverse effect in patients with no previous neurological problems.

Rerupture of intracranial aneurysms during angiography

We analyzed 70 patients (64 from the literature and 6 of our own cases) who had suffered from rerupture of their aneurysms during angiography. When these cases are compared with those who had suffered rupture of their aneurysms only once and a rerupture, which did not coincide with angiography, they were clinically distinguished by a higher Hunt-Hess grade, a higher rate of IC aneurysms, less operability, far miserable outcome and concentration of aneurysmal rerupture within three hours after the initial subarachnoid haemorrhage. It is suggested waiting at least 3 hours after SAH before performing angiography and to use digital subtraction angiography in order to prevent aneurysmal rerupture during angiography.

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 therapy in patients with aneurysmal subarachnoid haemorrhage

In a prospective consecutive non-randomised study including 1076 patients with ruptured intracranial aneurysms 205 patients received epsilon aminocraproic acid (EACA) and 871 did not. No significant differences between the two groups concerning clinical condition on admission, sex, age, localisation and size of the aneurysms were seen. No cases of rebleeding (RB) were observed within the first 4 days in the EACA treated patients, but within the first 48 hours, which is the optimal period recommended for operation of patients in good clinical condition, this difference of the rates of RB between EACA treated and not treated patients is not significant. A significantly lower rate of RB was observed in the EACA group within the first 2 weeks, but no significant differences in morbidity and mortality were found at the 2-year follow-up examination.

The risk of rebleeding from ruptured intracranial aneurysms

In the 5-year period from 1978 to 1983, 1076 patients with ruptured intracranial aneurysms were admitted to the six neurosurgical departments in Denmark and were entered in a prospective consecutive study conducted by the Danish Aneurysm Study Group. The patients were followed with 3-month and 2-year examinations or to death. A total of 133 patients suffered at least one rebleed after their initial hemorrhage during their first stay in the neurosurgical department; these patients had a mortality rate of 80% compared to 41% for patients without a rebleed (p less than 0.0001). During the first 2 weeks after the initial insult, 102 rebleeds were registered. The daily rate of rebleeds during these 2 weeks, calculated using a life-table method, varied from 0.2% to 2.1%. The rebleed rate during the first 24 hours (Day 0) was 0.8%, and the maximum risk of rebleeding was observed between Day 4 and Day 9. Significantly fewer rebleeds were reported in patients with good clinical grades (Grades 1 to 3, Hunt Grades I and II) compared to those with poor clinical grades (Grades 4 to 9, Hunt Grades III to V: p less than 0.001).

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.

Cerebral vasospasm following aneurysmal subarachnoid hemorrhage

Cerebral vasospasm following aneurysmal subarachnoid hemorrhage is one of the most important causes of cerebral ischemia, and is the leading cause of death and disability after aneurysm rupture. There are two definitions of cerebral vasospasm: angiographic and clinical. Care must be exercised to be certain that it is clear which entity is being addressed. The diagnosis of the clinical syndrome is one of exclusion and can rarely be made with absolute certainty. The pathogenesis of cerebral vasospasm is poorly understood. Most current theories focus on the release of factors from the subarachnoid clot. More attention must be given to the role of endothelial damage and alterations in the blood-arterial wall barrier. The application of modern techniques for studying vascular smooth muscle which have been developed as a result of research in the areas of hypertension and atherosclerosis must be applied to the problem of cerebral vasospasm. A stress test to select patients with angiographic arterial narrowing who have adequate cerebral vascular reserve to undergo surgery should be developed. The optimal treatment of vasospasm awaits development of agents for blocking or inactivating spasmogenic substances or blocking arterial smooth muscle contraction. Rheological or hemodynamic manipulations to prevent or reverse ischemic consequences of vasospasm are relatively effective, but complicated and hazardous, and should be viewed principally as interim measures awaiting development of more specific therapies for the arterial narrowing.

Outcome from "rescue clipping" of ruptured intracranial aneurysms during induction anaesthesia and endotracheal intubation

Eight patients with ruptured aneurysms during induction anaesthesia and endotracheal intubation underwent an emergency "rescue clipping" of their lesion. Three patients died. Of the five survivors three made a good final recovery, one patient was moderately disabled and one remained in coma. Conservative management of this crisis is doomed to failure but the comparatively good outcome of the operative cases supports emergency "rescue clipping".

Epsilon amino caproic acid myopathy: additional features

In a patient with a proximal myopathy due to Epsilon Amino Caproic Acid (EACA) bedrest led to marked improvement even before withdrawal of the drug. A biopsy showed a selective necrosis of type I fibers. Plasma level of EACA was low and plasma level of lysine was normal. A 99mTechnetium-MDP showed marked uptake in the affected muscles, whereas a 67Gallium scan was negative.

Why may epsilon-aminocaproic acid (EACA) induce myopathy in man? Report of a case and literature review

A case of necrotizing myopathy due to a short epsilon-aminocaproic acid (EACA) treatment in a 72 year-old patient with subarachnoid haemorrhage (SAH) is described. Pathogenetic hypotheses are discussed.

Cerebral vasospasm after subarachnoid hemorrhage: an update

Symptomatic vasospasm, or delayed cerebral ischemia associated with arteriographic evidence of arterial constriction, is currently the most important cause of morbidity after acute subarachnoid hemorrhage. The development of vasospasm is directly correlated with the presence of thick blood clots in the basal subarachnoid cisterns, which can be detected by an early computed tomographic scan. Symptomatic vasospasm usually develops between 4 and 12 days after subarachnoid hemorrhage. The onset is gradual, occurring over hours or days. There is typically a gradual deterioration of the level of consciousness, accompanied by focal neurological deficits that are determined by the arterial territories involved. Hyponatremia frequently occurs and may exacerbate the symptoms. The patients are usually volume depleted, and therefore many authorities now treat them with replenishment and expansion of their intravascular volume with colloid and blood. Volume expansion, together with elevation of the systemic blood pressure and reduction of the intracranial pressure when elevated, constitute the only currently available effective therapy for symptomatic vasospasm. The cause of vasospasm remains obscure. Mechanisms of smooth muscle cell contraction and relaxation and experimental efforts to elucidate the nature of vasospasm are reviewed.

Monitoring of antifibrinolytic therapy following subarachnoid hemorrhage. The importance of CSF fibrin/fibrinogen degradation products

Ten cases of subarachnoid hemorrhage (SAH) from ruptured cerebral aneurysm are reported. Fibrin/fibrinogen degradation product (FDP) levels were determined simultaneously in blood and cerebrospinal fluid (CSF) at an average frequency of 1.7 days, extended over periods of 8 to 63 days. Successful antifibrinolytic therapy (AFT) correlated with FDP levels in CSF of less than 16 micrograms/ml. Five patients failed to respond to AFT. Levels of FDP in the CSF fluctuated widely in these five patients, and remained at or above 16 micrograms/ml for most of the monitoring period. Blood FDP levels were normal or minimally elevated, and could not be used in predicting or preventing rebleeding episodes. A hypothesis is presented to explain the significance of the presence of FDP's in CSF. In spite of the many techniques employed in monitoring AFT and reviewed in this paper, little information has been gained to improve the results and therapeutic strategies. Among the different methods available, FDP measurements in the CSF have correlated best with rebleeding, and thus may be used in modifying and individualizing therapy. Suggestions are given for future studies.