Impact of a Protocol for Acute Antifibrinolytic Therapy on Aneurysm Rebleeding After Subarachnoid Hemorrhage

Abstract

Background and Purpose--Aminocaproic acid (EACA) is an antifibrinolytic agent used to prevent rebleeding in aneurysmal subarachnoid hemorrhage. Although studies have found that a decrease in rebleeding with long-term antifibrinolytic therapy is offset by an increase in ischemic deficits, more recent studies have indicated that early, short-term therapy may be beneficial. Methods-We instituted a protocol for acute EACA administration starting at diagnosis and continued for a maximum duration of 72 hours after subarachnoid hemorrhage onset. We compared 73 patients treated with EACA with 175 non-EACA-treated patients. We sought to identify differences in the occurrence of rebleeding, side effects, and outcome. Results-Baseline characteristics were similar in the 2 groups. There was a significant decrease in rebleeding in EACA-treated patients (2.7%) versus non-EACA patients (11.4%). There was no difference in ischemic complications between cohorts. There was a significant 8-fold increase in deep venous thrombosis in the EACA group but no increase in pulmonary embolism. There was a nonsignificant 76% reduction in mortality attributable to rebleeding, a 13.3% increase in favorable outcome in good-grade EACA-treated patients, and a 6.8% increase in poor-grade patients. Conclusions-When used acutely, short-term EACA treatment resulted in decreased rebleeding without an increase in serious side effects in our selected group of patients. Randomized placebo-controlled trials are needed to determine whether acute antifibrinolytic therapy should be accepted as the standard of care in all patients.

Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage

“…Such use led to a decreased incidence in rebleeding without increasing the risk of DCI, but 3-month clinical outcomes were not affected. 138 There was an increased risk of deep venous thrombosis but not pulmonary embolism. Neither aminocaproic acid nor tranexamic acid is approved by the US Food and Drug Administration for prevention of aneurysm rebleeding.…”

The Critical Care Management of Aneurysmal Subarachnoid Hemorrhage

“…However, no study to date has been powered adequately to assess clinical outcome benefit with early short duration antifibrinolytic therapy. One study, however, has shown an increase in the rate of DVT's associated with the use antifibrinolytic therapy [25]. The Neurocritical Care Society's consensus statement on management of SAH recommends considering an initial early short course of an antifibrinolytic with early definitive treatment of the aneurysm [26].…”

Intracranial Hemorrhage

“…A prospective trial found that up to 72 hours of tranexamic acid substantially reduced the risk of aneurysm rebleeding with minimal thrombotic side effects (86). Aminocaproic acid use is also associated with a reduced risk of rebleeding (87).…”