Seminars in Neurosurgery 2000; 11(1): 3-16
DOI: 10.1055/s-2000-11553
Copyright © 2000 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

PROTECTION FROM REBLEEDING BEFORE EARLY ANEURYSM SURGERY

Thomas J. Leipzig, Terry G. Horner, Troy D. Payner, Kathleen Redelman
  • Indianapolis Neurosurgical Group, Inc., Indianapolis, Indiana
Further Information

Publication History

Publication Date:
31 December 2000 (online)

 

ABSTRACT

Successful surgical or endovascular occlusion of a ruptured intracranial aneurysm virtually eliminates the potential for a recurrent subarachnoid hemorrhage (SAH). Although these procedures are commomly performed in the early period following aneurysmal hemorrhage, the patient remains at risk for a potentially fatal rebleed until the aneurysm is successfully obliterated. A variety of logistic delays invariably prevents the immediate treatment of a ruptured aneurysm. Indeed, the greatest risk for recurrent hemorrhage may be in the first 6-24 hr following the initial rupture, precisely the time during which the patient is undergoing initial assessment.

During a period of 111/2 years, we treated over 1000 patients with a ruptured saccular aneurysm. We have specifically analyzed 467 of these patients with a Hunt and Hess grade of I-III who were scheduled for early surgical intervention. We examined the use of antifibrinolytic therapy prior to early surgery in these patients. We will discuss the rationale for this treatment and provide an update of our results with antifibrinolysis. Also, we will review other strategies that may be beneficial to patients in the early period following aneurysmal SAH. Neurosurgeons need to maintain attention to this relatively brief but critical period between rupture of an aneurysm and its successful occlusion.

KEYWORD

Aneurysm - rebleed - antifibrinolytic therapy

REFERENCES

  • 1 Rosenørn J, Eskesen V, Schmidt K. The risk of rebleeding from ruptured intracranial aneurysms.  J Neurosurg . 1987;  67 329-332
    CrossrefPubMedGoogle Scholar
  • 2 Kassell N F, Torner J C, Haley Jr C E. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical results.  J Neurosurg . 1990;  73 37-47
    CrossrefPubMedGoogle Scholar
  • 3 Ausman J I, Diaz F G, Ghaus M M. Management of cerebral aneurysms: Further facts and additional myths.  Surg Neurol . 1989;  32 21-35
    PubMedGoogle Scholar
  • 4 Batjer H H. Timing of operation for ruptured aneurysms: early surgery. In: Ratcheson RA, Wirth FP, eds. Ruptured Cerebral Aneurysms: Perioperative Management, Vol 6: Concepts in Neurosurgery. Baltimore, MD: Williams & Wilkins 1994: 46-53
    Google Scholar
  • 5 Jane J A, Kassell N F, Torner J C. The natural history of aneurysms and arteriovenous malformations.  J Neurosurg . 1985;  62 321-323
    CrossrefPubMedGoogle Scholar
  • 6 Kassell N F, Drake C G. Review of the management of saccular aneurysms.  Neurol Clin . 1983;  1 73-86
    PubMedGoogle Scholar
  • 7 Kassell N F, Drake C G. Timing of aneurysm surgery.  Neurosurgery . 1982;  10 514-519
    CrossrefPubMedGoogle Scholar
  • 8 Crowell R M, Gress D R, Ogilvy C S. Principles of management of subarachnoid hemorrhage: General management. In: Ratcheson RA, Wirth FP, eds. Ruptured Cerebral Aneursyms: Perioperative Management, Vol 6: Concepts in Neurosurgery. Baltimore, MD: Williams & Wilkins 1994: 59-76
    Google Scholar
  • 9 Mullan S. Principles of management of subarachnoid hemorrhage: induced hypotension. In: Ratcheson RA, Wirth FP, eds. Ruptured Cerebral Aneurysms: Perioperative Management, Vol 6. Baltimore, MD: Williams & Wilkins, 1994: 97-104
    Google Scholar
  • 10 Hillman J, von Essen C, Leszniewski W. Significance of ``ultra-early'' rebleeding in subarachnoid hemorrhage.  J Neurosurg . 1988;  68 901-907
    PubMedGoogle Scholar
  • 11 Leipzig T J, Redelman K, Horner T J. Reducing the risk of rebleeding before early aneurysm surgery: A possible role for antifibrinolytic therapy.  J Neurosurg . 1997;  86 220-225
    PubMedGoogle Scholar
  • 12 Mullan S, Dawley J. Antifibrinolytic therapy for intracranial aneurysms.  J Neurosurg . 1968;  28 21-23
    PubMedGoogle Scholar
  • 13 Bergin J J. The complications of therapy with epsilon-aminocaproic acid.  Med Clin N Am . 1966;  50 1669-1678
    PubMedGoogle Scholar
  • 14 Adams Jr P H, Nibbelink D W, Torner J C. Antifibrinolytic therapy in patients with aneurysmal subarachnoid hemorrhage.  Arch Neurol . 1981;  38 25-29
    PubMedGoogle Scholar
  • 15 Adams Jr H P, Nibbelink D W, Torner J C. Antifibrinolytic therapy in patients with aneurysmal subarachnoid hemorrhage. In: Sahs AL, Nibbelink DW, Torner JC, eds. Aneurysmal Subarachnoid Hemorrhage: Report of the Cooperative Study Baltimore, MD: Urban and Schwarzenberg 1981: 331-339
    Google Scholar
  • 16 Fodstad H, Liliequist B, Schannong M. Tranexamic acid in the preoperative management of ruptured intracranial aneurysms.  Surg Neurol . 1978;  10 9-15
    PubMedGoogle Scholar
  • 17 Kassell N F, Torner J C. Aneurysmal rebleeding: A preliminary report from the Cooperative Aneurysm Study.  Neurosurgery . 1983;  13 479-481
    CrossrefPubMedGoogle Scholar
  • 18 Ramirez-Lassepas M. Antifibrinolytic therapy in subarachnoid hemorrhage caused by ruptured intracranial aneurysm.  Neurology . 1981;  31 316-322
    PubMedGoogle Scholar
  • 19 Vermeij F H, Hasan D, Bijvoet H WC. Impact of medical treatment on the outcome of patients after aneurysmal subarachnoid hemorrhage.  Stroke . 1998;  29 924-930
    PubMedGoogle Scholar
  • 20 Adams Jr P H. Antifibrinolytics in aneurysmal subarachnoid hemorrhage: Do they have a role?.  Maybe. Arch Neurol . 1987;  44 114-115
    PubMedGoogle Scholar
  • 21 Fodstad H, Forssell A, Liliequist B. Antifibrinolysis with tranexamic acid in aneurysmal subarachnoid hemorrhage: A consecutive controlled clinical trial.  Neurosurgery . 1981;  8 158-165
    PubMedGoogle Scholar
  • 22 Kassell N F, Torner J C, Adams Jr P H. Antifibrinolytic therapy in the acute period following aneurysmal subarachnoid hemorrhage. Preliminary observations from the Cooperative Aneurysm Study.  J Neurosurg . 1984;  61 225-230
    CrossrefPubMedGoogle Scholar
  • 23 Weir B. Antifibrinolytics in subarachnoid hemorrhage. Do they have a role?.  <~>No. Arch Neurol . 1987;  44 116-118
    PubMedGoogle Scholar
  • 24 Vermuelen M, Lindsay K W, Murray G D. Antifibrinolytic treatment in subarachnoid hemorrhage.  N Engl J Med . 1984;  311 432-437
    PubMedGoogle Scholar
  • 25 Hachinski V. Antifibrinolytics in subarachnoid hemorrhage.  Arch Neurol . 1987;  44 118
    PubMedGoogle Scholar
  • 26 Mullan S. The initial medical management of ruptured intracranial aneurysms. In: Morley TP, ed. Current Controversies in Neurosurgery Philadelphia, PA: WB Saunders 1976: 259-269
    Google Scholar
  • 27 Nibbelink D W, Torner J C, Henderson W G. Intracranial aneurysms and subarachnoid hemorrhage. A cooperative study. Antifibrinolytic therapy in recent onset subarachnoid hemorrhage.  Stroke . 1975;  6 622-629
    PubMedGoogle Scholar
  • 28 Shucart W A, Hussain S K, Cooper P R. Epsilon-aminocaproic acid and recurrent subarachnoid hemorrhage.  J Neurosurg . 1980;  53 28-31
    PubMedGoogle Scholar
  • 29 Vermeulen M, Muizelaar J P. Do antifibrinolytic agents prevent rebleeding after rupture of a cerebral aneurysm?.  <~>A review. Clin Neurol Neurosurg . 1980;  82 25-30
    PubMedGoogle Scholar
  • 30 Muizelaar J P. Perioperative management of subarachnoid hemorrhage.  Contemp Neurosurg . 1990;  12 1-6
    CrossrefPubMedGoogle Scholar
  • 31 Jane J A, Winn H R, Richardson A E. The natural history of intracranial aneurysms: Rebleeding rates during the acute and long term period and implication for surgical management. In: Keener EB, ed. Clinical Neurosurgery, Vol 24. Baltimore, MD: Williams & Wilkins 1976: 176-184
    Google Scholar
  • 32 Fodstad H, Pilbrant A, Schannong M. Determination of tranexamic acid (ACMA) and fibrin/fibrinogen degradation products in cerebrospinal fluid after aneurysmal subarachnoid hemorrhage.  Acta Neurochir . 1981;  58 1-13
    CrossrefPubMedGoogle Scholar
  • 33 McNicol G P, Fletcher A P, Alkjaersig N. The absorption, distribution and excretion of epsilon-aminocaproic acid following oral or intravenous administration to man.  J Lab Clin Med . 1962;  59 15-24
    PubMedGoogle Scholar
  • 34 Moffat A C, Jackson J V, Moss M S, et a l, eds. Clarke's Isolation and Identification of Drugs in Pharmaceuticals, Body Fluids and Post-Mortem Material, 2nd e d. London, UK: The Pharmaceutical Press; . 1986: 341
    Google Scholar
  • 35 Smith R R, Upchurch J J. Monitoring antifibrinolytic therapy in subarachnoid hemorrhage.  J Neurosurg . 1973;  38 339-344
    PubMedGoogle Scholar
  • 36 Wyngaarden J B, Smith Jr H L, Bennett J C, eds. Cecil Textbook of Medicine, V ol. 2, 19th ed.  Philadelphia, PA: WB Saunders 1992: 2377
    Google Scholar
  • 37 Fujii Y, Takeuchi S, Sasaki O. Ultra-early rebleeding in spontaneous subarachnoid hemorrhage.  J Neurosurg . 1996;  84 35-42
    CrossrefPubMedGoogle Scholar
  • 38 Hunt W E, Hess R M. Surgical risk as related to time of intervention in the repair of intracranial aneurysms.  J Neurosurg . 1968;  28 14-20
    CrossrefPubMedGoogle Scholar
  • 39 Heros R C, Korosue K. Hemodilution for cerebral ischemia.  Stroke . 1989;  20 423-427
    PubMedGoogle Scholar
  • 40 Kassell N F, Torner J C, Haley Jr C E. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results.  J Neurosurg . 1990;  73 18-36
    CrossrefPubMedGoogle Scholar
  • 41 Mancuso P A, Weinstein P R. Principles of management of subarachnoid hemorrhage: Pathophysiology and management of hydrocephalus after subarachnoid hemorrhage. In: Ratcheson RA, Wirth FP, eds. Ruptured Cerebral Aneurysms: Perioperative Management, Vol 6: Concepts in Neurosurgery. Baltimore, MD: Williams & Wilkins, 1994: 124-133
    Google Scholar
  • 42 Mayberg M R. Management of subarachnoid hemorrhage.  Stroke Clin Updates . 1995;  6 1-4
    PubMedGoogle Scholar
  • 43 Park B E. Spontaneous subarachnoid hemorrhage complicated by communicating hydrocephalus: Epsilon-amino-caproic acid as a possible predisposing factor.  Surg Neurol . 1979;  11 73-80
    PubMedGoogle Scholar
  • 44 Juvela S. Aspirin and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.  J Neurosurg . 1995;  82 945-952
    PubMedGoogle Scholar
  • 45 Brown J A, Wollmann R L, Mullan S. Myopathy induced by epsilon-aminocaproic acid.  J Neurosurg . 1982;  57 130-134
    PubMedGoogle Scholar
  • 46 Glick R, Green D, Chung-hsin T. High dose epsilon-aminocaproic acid prolongs the bleeding time and increases rebleeding and intraoperative hemorrhage in patients with subarachnoid hemorrhage.  Neurosurgery . 1981;  9 398-401
    PubMedGoogle Scholar
  • 47 Tovi D, Nilsson I M, Thulin C A. Fibrinolysis and subarachnoid hemorrhage. Inhibitory effect of tranexamic acid. A clinical study.  Acta Neurol Scand . 1972;  48 393-402
    PubMedGoogle Scholar
  • 48 Feigin V L, Rinkel G JE, Algra A. Calcium antagonists in patients with aneurysmal subarachnoid hemorrhage. A systematic review.  Neurology . 1998;  50 876-883
    CrossrefPubMedGoogle Scholar
  • 49 Scott J A, Horner T G, Leipzig T J. Retrograde suction decompression of an ophthalmic artery aneurysm using balloon occlusion. Technical note.  J Neurosurg . 1991;  75 146-147
    CrossrefPubMedGoogle Scholar
  • 50 Solomon R A, Smith C R, Raps E C. Deep hypothermic circulatory arrest for the management of complex anterior and posterior circulation aneurysms.  Neurosurgery . 1991;  29 732-739
    PubMedGoogle Scholar
  • 51 Ingawa T. Ultra-early rebleeding within six hours after aneurysm rupture.  Surg Neurol . 1994;  42 130-134
    PubMedGoogle Scholar
  • 52 Ingawa T, Kamiya K, Ogasawara H. Rebleeding of ruptured intracranial aneurysms in the acute stage.  Surg Neurol . 1987;  28 93-99
    PubMedGoogle Scholar
  • 53 Juvela S. Rebleeding from intracranial aneurysms.  Surg Neurol . 1989;  32 323-326
    PubMedGoogle Scholar
  • 54 Komiyama M, Tamura K, Nagata Y. Aneurysmal rupture during angiography.  Neurosurgery . 1993;  33 798-803
    CrossrefPubMedGoogle Scholar
  • 55 Mullan S. Principles of management of subarachnoid hemorrhage: antifibrinolysis. In: Ratcheson RA, Wirth FP, eds. Ruptured Cerebral Aneurysms: Perioperative Management, Vol 6: Concepts in Neurosurgery. Baltimore, MD: Williams & Wilkins 1994: 86-96
    Google Scholar
  • 56 Laohaprasit V, Edwards M W, Mayberg M R. Prevention of postoperative intracerebral hemorrhage with topical recombinant factor XIII in the rat.  Neurosurgery . 1993;  32 630-634
    PubMedGoogle Scholar
  • 57 Corkill G. Earlier operation and antifibrinolytic therapy in management of aneurysmal subarachnoid hemorrhage. Review of recent experience in Tasmania.  Med J Aust . 1974;  1 468-470
    PubMedGoogle Scholar
  • 58 Mullan S, Hanlon K, Brown F. Management of 136 consecutive supratentorial berry aneurysms.  J Neurosurg . 1978;  49 794-8041
    PubMedGoogle Scholar
      >