Use Of Antifibrinolytic Therapy Research Articles

Use of antifibrinolytic therapy in orthopedic surgery: a review

Total joint arthroplasties, trauma, and spine surgery are correlated with a significant amount of bleeding. The severity of the bleeding might be substantial enough to require a blood transfusion to treat the resulting anemia. Antifibrinolytic therapy is used to reduce blood loss in orthopedic surgery. This review aimed to assess the recent research supporting the use of antifibrinolytic therapy to reduce blood loss in orthopedic surgery. In the last 10 years, the published studies determining antifibrinolytic therapy's effect on orthopedic surgery were searched in Google Scholar and PubMed. Antifibrinolytic agents are used in most surgical operations, including orthopedic surgery. It causes a significant reduction in blood loss and blood transfusion. In addition, antifibrinolytic therapy did not increase the risk of deep vein thrombosis in patients undergoing total joint arthroplasty. Tranexamic acid, epsilon aminocaproic acid, and aprotinin are the most popular fibrinolytic agents. Tranexamic acid is more frequently used in patients undergoing joint replacement, spine and trauma surgery. . Although aminocaproic acid has a more limited history of usage in orthopedic surgery than tranexamic acid, it has a more significant antifibrinolytic effect.

Застосування антифібринолітичної терапії у періопераційному періоді у дітей та дорослих

перебіг оперативних втручань у дітей можуть ускладнюватися розвиткомперіопераційної кровотечі. Застосування препаратів із антифібринолітичною дією зменшуєта превентує розвиток інтраопераційної крововтрати у дорослих та пацієнтів дитячого віку.Антифібринолітичні препарати такі, як транексамова кислота (ТКК) проявила свою ефективністьу якості зменшення обсягу періопераційної крововтрати, трансфузії у дорослих пацієнтів тадітей при травмі, кардіохірургічних та великих ортопедичних втручань. Проте використанняданого препарату у категорії пацієнтів високого ризику та у навантажувальних дозах > 100 мг/кг може асоціюватися із розвитком тромбоемболічних та судомних ускладнень. Однією із перевагзастосування амінокапронової кислоти (АКК) є її широка доступність, вартість і водночасефективність. Порівнюючи ефективність лізинових похідних у пацієнтів із краніостенозомА. Borst, C. Bonfield зазначають, що при використанні АКК в порівнянні із ТКК підвищуєтьсярівень інтраопераційної крововтрати (21 ± 13 vs. 17 ± 10), проте статистично вона не є значима.Апротинін, у якості препарату для зменшення крововтрати у кардіохірургічних пацієнтів впорівнянні із лізиновими похідними, являється більш ефективним для зниження періопераційної
 крововтрати. Проте після дослідження The Blood Conservation Using Antifibrinolytics in a Random-ized Trial (BART) (Fergusson D. et al. 2008) є обмежено доступний у багатьох країнах через високу
 кількість тромбоемболічних ускладнень та підвищену смертність. На даний момент активнодосліджуються протизапальні властивості не лише апротиніну, а й ТКК та АКК.

Is Antifibrinolytic Therapy Effective for Preventing Hemorrhage in Patients with Hemophilia Undergoing Dental Extractions? A Systematic Review and Meta-Analysis

ObjectivesThis systematic review aims to analyze the systemic administration of antifibrinolytics (tranexamic acid and aminocaproic acid) to prevent postoperative bleeding in patients with hemophilia.MethodsThis systematic review was conducted adhering to PRISMA guidelines. Only randomized controlled trials that assessed human subjects of any age or gender with any severity of hemophilia undergoing dental extractions, and systemically administered antifibrinolytic therapy compared to placebo were included. Post-operative bleeding episodes and adverse events were presented. PubMed, Cochrane, Embase, CINAHL, Web of Science, and Scopus were searched through April 15, 2022. The risk ratio (RR) and odds ratio (OR) applying 95% confidence intervals (CI) were computed using RevMan 5.4.1 (Cochrane).ResultsTwo randomized, placebo-controlled trials pooling in a total of 59 patients were pooled in this analysis. Among patients administered antifibrinolytic therapy, 84% reduced risk of post-operative bleeding was reported (RR = 0.16, 95% CI = 0.05–0.47, P = 0.0009). The chances of post-operative bleeding were reduced by 95% among the antifibrotics group (OR = 0.05, 95% CI = 0.01–0.22, P < 0.0001).ConclusionThis review finds favorable outcomes for the routine use of antifibrinolytic therapy for dental extractions in hemophiliacs. Further trials are required to rationalize existing evidence.

Aneurysmal subarachnoid hemorrhage: current concepts and updates.

Aneurysmal subarachnoid hemorrhage is a condition with a considerable incidence variation worldwide. In Brazil, the exact epidemiology of aneurysmal SAH is unknown. The most common presenting symptom is headache, usually described as the worst headache ever felt. Head computed tomography, when performed within six hours of the ictus, has a sensitivity of nearly 100%. It is important to classify the hemorrhage based on clinical and imaging features as a way to standardize communication. Classification also has prognostic value. In order to prevent rebleeding, there still is controversy regarding the ideal blood pressure levels and the use of antifibrinolytic therapy. The importance of definitely securing the aneurysm by endovascular coiling or surgical clipping cannot be overemphasized. Hydrocephalus, seizures, and intracranial pressure should also be managed. Delayed cerebral ischemia is a severe complication that should be prevented and treated aggressively. Systemic complications including cardiac and pulmonary issues, sodium abnormalities, fever, and thromboembolism frequently happen and may have na impact upon prognosis, requiring proper management.

Coagulation Profile of Patients with Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion.

Blood loss and transfusion requirements during posterior spinal fusion for adolescent idiopathic scoliosis remain a concern. The mechanism of bleeding in these patients is poorly characterized. Thromboelastography is a comprehensive test of a patient's coagulation system commonly used in cardiac surgical procedures. It has not been well studied for use in patients with adolescent idiopathic scoliosis. A prospective, observational study of the coagulation profile of patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion is presented. Healthy patients with adolescent idiopathic scoliosis without a bleeding abnormality were analyzed during posterior spinal fusion. Standard coagulation laboratory and thromboelastogram measures were obtained at the time of the incision and at 1-hour intervals during the surgical procedure. Laboratory values were analyzed in relation to outcomes such as bleeding, transfusion, and a fibrinolysis score. Fifty-eight patients were observed. Eighty-one percent of patients were female, the mean age was 13.5 years, a mean of 11.1 levels were fused, the median estimated blood loss was 645 mL, and 47% of patients received blood products. Overall, laboratory values remained stable throughout the surgical procedure. Mild increases in prothrombin time and partial thromboplastin time were observed, and platelets remained stable. From thromboelastogram analysis, an acceleration of clot formation (decreased reaction time) and a slight increase in clot lysis (increased lysis percentage at 30 minutes) were observed. A fibrinolysis score compiled from the presence of fibrin degradation products, the presence of D-dimers, and increased prothrombin time rose steadily over surgical time. The fibrinolysis score was predictive of both transfusion and greater estimated blood loss per level. The stress of posterior spinal fusion induces a hypercoagulable state in patients with adolescent idiopathic scoliosis. Over the first 2 hours of a surgical procedure, varying degrees of fibrinolysis develop. Platelets and coagulation factors are not depleted. Our data support the use of antifibrinolytic therapy for patients with adolescent idiopathic scoliosis.

Современные подходы к коррекции гемостаза при оперативных вмешательствах по поводу гигантских миом матки

Целью исследования было снижение периоперационной кровопотери у больных с гигантской миомой матки. В результате исследования были получены данные о том, что использование антифибринолитической терапии в виде назначения транексамовой кислоты за 30 минут до оперативного вмешательства в дозе 20 мг/кг с последующей инфузией 5 мг/кг в час в течение первых послеоперационных суток позволяет снизить периоперационную кровопотерю на 29 %. У больных второй группы уровень гемоглобина на вторые послеоперационные сутки был выше на 10 % (р &lt; 0,05), кровопотеря была ниже на 29 % (р &lt; 0,05), сроки пребывания в стационаре были меньше на 24 % (р &lt; 0,05).

Postpartum hemorrhage: a continuing challenge.

Obstetric hemorrhage remains a leading cause of maternal morbidity and mortality worldwide. Many postpartum hemorrhages (PPHs) do not have identifiable risk factors; maternity units should therefore have obstetric hemorrhageprotocols in place for all parturients as every pregnancy has the potential to be complicated by hemorrhage. This review will examine the epidemiology of PPH as well as current recommendations for key elements in obstetric hemorrhage protocols. Recent advances in hematologic management of PPH will be also be reviewed, including: (1) recognition of hypofibrinogenemia as a risk factor for severe PPH, (2) use of antifibrinolytic therapy, and (3) strategies for fibrinogen replacement therapy.

Preparation of patients with hemophilia A for oral surgery

Hemophilia A is an inherited disease characterized by deficiency of coagulation factor VIII and bleeding tendency. It is transmitted through the X chromosome. Hemophilia A is characterized by excessive bleeding in various tissues of the body, including soft tissue hematomas and hemarthrosis. In formulating the diagnosis of hemophilia A, in addition to a well-taken medical history and physical examination, laboratory tests should also be carried out and analyzed. Tooth extraction is the most common surgical procedures in patients with hemophilia. Hematological preparation implies the application of a concentrated factor VIH for one to two days prior to the intervention to achieve a desired level of factor VIII needed for the operation. In tooth extraction, this level has to be 50% before and after the tooth extraction for 5 days, with the application of antifibrinolytic agents. In oral surgical interventions the desired level of factor VIII is 50-80% preoperatively, 30-80% for 5 days after surgery, and 30% up to 14 days, also with the use of antifibrinolytic therapy. Patients with hemophilia and inhibitors are prepared for intervention through the application of recombinant FVIIa at the dose of 120mcg/kg, repeated every 2 hours for the period of 7-10 days after the intervention. It is necessary to apply antifibrinolytic agents and local hemostatic measures. Measures of local hemostasis are unavoidable in the case of oral surgical interventions in patients with hemophilia A. Implementation of these procedures in oral surgery has the role of minimizing the possibility of intra- and postoperative bleeding in patients with hemophilia A. For this purpose, the following are mostly used: absorbable suture thread, preparations of collagen, oxycellulose, gelatin, fibrin glue, with topical application of tranexamic or epsilon aminocaproic acid. Conclusion: Close cooperation between hematologists and oral surgeons is essential in order to minimize unwanted complications in patients with hemophilia A.

The effect of antifibrinolytic therapy on complications, blood product utilization, and fusion in adult spinal deformity

Antifibrinolytic therapy (AF) has been shown to be effective in preventing blood loss in some settings. Its effect in patients undergoing adult spinal deformity (ASD) surgery remains unclear. This study looks at the use of antifibrinolytic therapy in adult spinal deformity surgery and its effect on major and minor perioperative complications, blood product utilization, vascular events and postoperative fusion. A multicenter prospective consecutive database of surgical ASD patients was reviewed. Complications were divided into intra-operative and perioperative (within 6 weeks). Parameters of blood product utilization included the rate of transfusion, and the units of PRBCs and FFP transfused. Thromboembolic events included stroke, deep venous thrombosis (DVT) and pulmonary embolus (PE). Fusion rates at 2 years were measured on AP and lateral radiographs at using the Lenke classification. The impact of AF use on complications, blood product utilization, vascular events and fusion rates was studied using multivariate logistic, ordinal logistic, or poisson regression, as appropriate. Models accounted for confounders as determined by univariate analysis and expert opinion. In total, 403 patients were included, 137 patients received aminocaproic acid (ACA), 81 received tranexamic acid (TXA), 185 received no AF, 227 patients had two-year radiographic data. The use of AF was associated with a decrease in transfusion (ACA OR 0.38 P = 0.043, TXA 0.31 P = 0.047), a decrease in the number of units of PRBCs transfused (ACA IRR 0.45 P = 0.0005, TXA IRR 0.7 P = 0.0005), and a decrease in the number of FFP transfused (ACA IRR 0.65 P = 0.003, TXA IRR 0.67 P = 0.006). The use of TXA (but not ACA) was associated with a decrease the incidence of major perioperative complications compared to no AF (IRR 0.37, P = 0.019). AF use was not associated with an increase in thromboembolic events. The use of AF did not impact the fusion rates at 2 years. The use of TXA or ACA was associated with increased minor intra-operative complications. TXA was associated with decreased major perioperative complications. AF was associated with decreased utilization of blood products without an increased rate of thromboembolic events. Given the observational nature of this study, transfusion threshold was not standardized across the study sites. Future studies with rigid criteria for transfusion should be prospectively performed to better evaluate AF use in ASD.

Antifibrinolytic Therapy To Prevent Early Rebleeding After Subarachnoid Hemorrhage

In the current era of early surgery, there has been little interest in the use of antifibrinolytic therapy to prevent rebleeding after aneurysmal subarachnoid hemorrhage (aSAH). Older studies demonstrated that antifibrinolytics can reduce rebleeding, but long-term therapy results in increased cerebral ischemia from vasospasm, leading to no appreciable effect on mortality. While early surgery would seem to obviate the need for long-term antifibrinolytic use, a subgroup of patients may benefit from early therapy. The rate of pre-operative rebleeding may be as high as 9-17%, causing significant morbidity and mortality. Short-term use of antifibrinolytic agents (less than 3 days) in the presence of calcium channel blocking therapy has shown promising results. A randomized clinical trial of early antifibrinolytic therapy conducted in 2002 showed a significant decrease in rebleeding and a non-significant decrease in overall mortality. In this review, we examine the clinical pharmacology, dosing, monitoring, complications, and side effects of antifibrinolytic treatment. We conclude that early short-term antifibrinolytic therapy might be a reasonable strategy to prevent acute rebleeding and improve long-term outcome in aSAH patients. Additional randomized clinical trials are necessary to determine whether this management strategy is effective.

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.

Anticoagulation, bleeding and blood transfusion practices in Australasian cardiac surgical practice

We surveyed contemporary Australasian cardiac surgical and anaesthetic practice, focusing on antiplatelet and antifibrinolytic therapies and blood transfusion practices. The cohort included 499 sequential adult cardiac surgical patients in 12 Australasian teaching hospitals. A total of 282 (57%) patients received red cell or component transfusion. The median (IQR) red cell transfusion threshold haemogloblin levels were 66 (61-73) g/l intraoperatively and 79 (74-85) g/l postoperatively. Many (40%) patients had aspirin within five days of surgery but this was not associated with blood loss or transfusion; 15% had clopidogrel within seven days of surgery. In all, 30 patients (6%) required surgical re-exploration for bleeding. Factors associated with transfusion and excessive bleeding include pre-existing renal impairment, preoperative clopidogrel therapy, and complex or emergency surgery. Despite frequent (67%) use of antifibrinolytic therapy, there was a marked variability in red cell transfusion rates between centres (range 17 to 79%, P < 0.001). This suggests opportunities for improvement in implementation of guidelines and effective blood-sparing interventions. Many patients presenting for surgery receive antiplatelet and/or antifibrinolytic therapy, yet the subsequent benefits and risks remain unclear.

A Case of Severe Diffuse Venous Thromboembolism Associated with Aprotinin and Hypothermic Circulatory Arrest in a Cardiac Surgical Patient with Factor V Leiden

A Case of Severe Diffuse Venous Thromboembolism Associated with Aprotinin and Hypothermic Circulatory Arrest in a Cardiac Surgical Patient with Factor V Leiden

Antifibrinolytic Use and Bleeding During Surgery on the Descending Thoracic Aorta: A Multivariate Analysis

The purpose of this study was to determine the potential benefit of antifibrinolytic (AF) therapy in improving hemostasis in descending aortic surgery in which extracorporeal distal perfusion is used. Retrospective database study. University hospital. Seventy-two patients who underwent descending thoracic or thoracoabdominal aortic replacement during the period from January 1993 through December 1996 when the use of AF therapy was emerging. None. Seventy-two records met criteria for inclusion. The use of AF therapy had no significant effect on any bleeding or transfusion outcome in any model. Excessive chest tube drainage postoperatively was independently associated with repeat surgery and intraoperative hypothermia. The risk of receiving a red blood cell (RBC) transfusion was independently predicted by low preoperative hemoglobin and age > or =65 years. Cross-clamp was an independent predictor of receiving a transfusion of non-RBC products (p = 0.03). The authors could not show a beneficial effect of AF therapy on bleeding and transfusion, although current practice shows that this therapy continues to be used. Because heterogeneity of patient population exists and bias cannot be completely excluded, a prospective investigation evaluating efficacy and safety in this population is warranted.

Thrombosis after Deep Hypothermic Circulatory Arrest with Antifibrinolytic Therapy: Is Factor V Leiden the Smoking Gun?

We appreciate the comments presented by Dr. Donahue regarding our report of two cases of fatal aortic thrombosis in association with synthetic antifibrinolytic therapy and deep hypothermic circulatory arrest. We agree that prospective large-scale association studies are necessary in order to make recommendations regarding genetic risk factors and the expenditure of healthcare dollars. The purpose of our report was not to definitively identify any causative agents or conditions in these thrombotic events, but merely to highlight their occurrence in a population of patients that is potentially at higher risk. Certainly, it would not be feasible to recommend that all asymptomatic patients scheduled to undergo cardiac surgery undergo genetic testing for a mutation in the expression of factor V. However, it behooves us as practitioners to be vigilant in our preoperative assessment of patients who may have a personal or a family history of hypercoagulability. This is true because even asymptomatic carriers of the factor V Leiden mutation have an appreciable incidence of thromboembolism that increases when risk factors for thrombosis are present. 1The use of antifibrinolytic therapy and the consumptive coagulopathy seen in cardiac surgical patients make this population quite distinct from orthopedic surgical patients or cardiovascular medicine patients in whom factor V Leiden has not been associated with increased thrombosis risk. Prophylactic antifibrinolytic therapy is given with impunity to hundreds of thousands of patients per year who undergo cardiac surgery. 2The use of these drugs has been of apparent benefit to blood conservation practices, but a careful risk-benefit analysis should be performed in light of the question of a small but worrisome possibility that fatal hypercoagulability may be associated with antifibrinolytic therapy.Since the publication of our case report, we have cared for a patient who experienced fatal intraoperative venous thrombosis in association with aprotinin therapy and deep hypothermia during valve replacement surgery. While the analysis of this case is ongoing, the initial investigation has shown that the patient's son carries the factor V Leiden mutation.Though causality should not be inferred from our small anecdotal experience, these types of associations are important in forming the basis for future population-based studies. Finally, the prudent clinician should carefully consider the relative risks and benefits of antifibrinolytic therapy in cardiac surgical patients with known hypercoagulable conditions, such as the factor V Leiden mutation.

Surgical repair of congenital diaphragmatic hernia during extracorporeal membrane oxygenation: Hemorrhagic complications and the effect of tranexamic acid

Extracorporeal membrane oxygenation (ECMO) was incorporated in a strategy of delayed repair of congenital diaphragmatic hernia (CDH) and was used for preoperative stabilization in patients who were unresponsive to maximal conventional treatment. If ECMO was required for preoperative stabilization the diaphragmatic defect was repaired while the patient was on ECMO. In the early experience with this approach all patients suffered from bleeding complications. Therefore, we adopted the use of antifibrinolytic therapy with tranexamic acid (TEA) during and immediately after CDH repair on ECMO. The efficacy of TEA was studied in an unblinded study using historical controls by comparing the postoperative blood loss and the transfusion requirements of red blood cells (RBC) in patient groups treated without (n = 9) and with TEA (n = 10). Patients who received TEA had significantly less bleeding at the surgical site than patients not receiving TEA (57 v 390 mL, P = .005) and had significantly lower RBC transfusion requirements than patients not receiving TEA (1.13 v 2.95 mL/kg/h, P = .03). In the very first two patients of the TEA group we encountered fairly severe thrombotic complications. TEA may have contributed to those complications. Based on the authors' experience they conclude: (1) TEA is effective in reducing postoperative blood loss, hemorrhagic complications, and RBC transfusion requirements associated with CDH repair on ECMO. (2) TEA may be responsible for thrombotic complications. (3) The appropriate, empirically established, dosage and administration patterns of TEA for CDH repair during ECMO seem to be one bolus of 4 mg/kg TEA intravenously 30 minutes before the anticipated CDH repair and a continuous infusion of 1 mg/kg/h TEA during the 24 hours after CDH repair.

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.

Antifíbrsnolytic Therapy and Cerebral Vasospasm

The role of antifibrinolytic drugs in the management of patients with aneurysmal subarachnoid hemorrhage continues to remain uncertain. Recent controlled studies suggest that although these agents may alter the course of the illness, they confer no benefit in terms of overall outcome. Confronted with these data, clinicians in North America have radically altered their management of patients with ruptured aneurysms in the last decade. In the Timing of Surgery Study (1980-1983), 54% of patients were treated with antifibrinolytic drugs and only 32% underwent surgical clipping of the aneurysm on days 0-3 from the subarachnoid hemorrhage. In contrast, only 13% of the patients in the Randomized Trial of Nicardipine in Subarachnoid Hemorrhage (1987-1989) received antifibrinolytics, whereas 53% had early surgery (unpublished observations). Further study will be required to determine if this strategy has resulted in an improvement in overall outcome. Some observers have suggested that as effective therapy for symptomatic vasospasm evolves (e.g., with hypertensive or hypervolemic therapy or calcium antagonists), the adverse effects of antifibrinolytic drugs on brain ischemia may be ameliorated. This idea must be confirmed by further evaluation of the combined use of these treatments. In the interim, antifibrinolytic drugs, if used at all, should be used with caution, and their use should be restricted to those patients judged not to be candidates for early surgery. If therapy cannot be started before day 7 after subarachnoid hemorrhage, it should not be started at all, as the reduced rate of rebleeding after the first 7 days does not justify the increased risk of brain ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Treatment of Traumatic Hyphema

<h3>To the Editor.—</h3> I refer to Dr Kershner's¹letter challenging the routine use of oral steroids for traumatic hyphema as advocated by Dr Yasuna.²Although the authors admit that the treatment of traumatic hyphema is controversial, I was surprised that neither author mentioned the use of antifibrinolytic therapy with aminocaproic acid for this condition. I feel it is important that the general medical community be informed about this therapy that is being recommended by experts in the field for routine use in the management of traumatic hyphema.³ Two prospective, double-blind, randomized clinical trials in humans^4,5plus one in rabbits⁶have been consistent in showing a 28% to 32% rebleeding rate in controls with only a 3% to 5% incidence of repeated hemorrhage in aminocaproic acid-treated eyes. The proposed mechanism involves competitive inhibition of the body's fibrinolytic system, thus preventing early fibrin dissolution before recently injured