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Antifibrinolytic therapy and cerebral vasospasm.
E C Haley1, J C Torner, N F Kassell
1Department of Neurology, University of Virginia School of Medicine, Charlottesville.
Neurosurgery Clinics of North America
|April 1, 1990
Summary
Antifibrinolytic drugs offer uncertain benefits for aneurysmal subarachnoid hemorrhage, potentially increasing risks without improving outcomes. Their use should be cautious and limited to specific patient groups.
Area of Science:
- Neurology
- Neurosurgery
- Pharmacology
Background:
- The role of antifibrinolytic drugs in aneurysmal subarachnoid hemorrhage (aSAH) management remains debated.
- Recent studies indicate these drugs may alter illness course but do not improve overall patient outcomes.
- Clinical practice in North America has shifted significantly regarding their use over the past decade.
Purpose of the Study:
- To evaluate the current role and impact of antifibrinolytic drugs in managing patients with aSAH.
- To analyze trends in antifibrinolytic use versus early surgical intervention for ruptured aneurysms.
- To assess the need for further research on antifibrinolytic therapy in conjunction with evolving vasospasm treatments.
Main Methods:
- Comparative analysis of treatment strategies from historical studies (Timing of Surgery Study) and more recent trials (Randomized Trial of Nicardipine in Subarachnoid Hemorrhage).
- Observation of changes in clinical management practices regarding antifibrinolytic drug administration and early surgery rates.
- Review of existing data on the efficacy and risks of antifibrinolytic agents in aSAH patients.
Main Results:
- A notable decrease in antifibrinolytic drug use and a corresponding increase in early surgical clipping for ruptured aneurysms between the early 1980s and late 1980s.
- Antifibrinolytic agents have not demonstrated clear benefits for overall patient outcomes despite potentially altering the disease course.
- Concerns exist regarding the adverse effects of antifibrinolytics on brain ischemia, particularly when not used judiciously.
Conclusions:
- Antifibrinolytic drugs should be used with caution in aSAH patients, primarily reserved for those not eligible for early surgery.
- Initiation of antifibrinolytic therapy after 7 days post-subarachnoid hemorrhage is not recommended due to unfavorable risk-benefit ratio.
- Further research is needed to clarify the role of antifibrinolytics, especially in combination with new therapies for vasospasm.