Antifibrinolytic Therapy

Antifibrinolytics, such as tranexamic acid, are a theoretically beneficial adjunct drugs that could help prevent the lysis of clot, thereby preventing a ruptured aneurysm from rebleeding. However, by disrupting the hemostatic balance, these drugs might also promote clot formation and complicate vasospasm management. Therefore, clinical trials have been conducted to clarify the role of these medications in the management of aSAH.

The earliest such study of tranexamic acid was conducted (in a double-blinded, placebo-controlled manner) in 51 patients who sustained SAH with tranexamic acid to prevent early rebleeding (7). Based on a three-month endpoint and analysis of outcomes, the authors concluded that tranexamic acid administration was associated with no significant change in outcomes. Since then, most trials of antifibrinolytic therapy (both randomized and observational), with enrollment ranging from approximately 60 to more than 600, have found that, although the antifibrinolytic might reduce early rebleeds, it is also associated with an increased rate of symptomatic vasospasm and relatively no difference in overall outcomes and mortality (8-12). Because of the increased rate of delayed ischemic neurologic deficits (DINDs), most centers opt for early surgical intervention rather than administering antifibrinolytics.

Recently, factor Vila has received attention as a possible means of preventing early rebleeding. It is a hemostatic therapy that promotes local hemostasis at sites of vascular injury, even in individuals in whom the coagulation cascade is otherwise normal. Randomized trials to assess the value of this therapy in patients with SAH have yet to be reported; however, a dose-escalation study has been published, with report of an ischemic complication halting the study (13).

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