Treatment of subarachnoid and other intracranial hemorrhages with proteinase inhibitors

Activation of the coagulation system in the subarachnoid space after subarachnoid haemorrhage: serial measurement of fibrinopeptide A and bradykinin of cerebrospinal fluid and plasma in patients with subarachnoid haemorrhage

Fibrinopeptide A (FPA) levels as an indicator of thrombin activity in the cerebrospinal fluid (CSF) and plasma of 25 patients with subarachnoid haemorrhage (SAH) were measured serially by radioimmunoassay (RIA). FPA levels in CSF were extremely high on days 0-1 (1253 +/- 269 ng/ml, mean +/- standard error) but decreased rapidly (11.3 +/- 3.9 ng/ml on days 2-4, 10.7 +/- 5.9 ng/ml on days 5-7, and 6.3 +/- 1.5 ng/ml on days 8-14). In the controls the FPA concentration in CSF was 1.2 +/- 0.9 ng/ml (mean +/- standard deviation). Plasma FPA levels in patients with SAH showed no statistically significant changes with time. The bradykinin (BK) concentration in CSF and plasma in 27 patients with SAH was measured serially by RIA. The concentrations in CSF were 122.7 +/- 22.7 pg/ml (mean +/- standard error) on day 0, 38.6 +/- 6.1 pg/ml on day 1, 22.7 +/- 6.3 pg/ml on day 2, and 17.1 +/- 3.0 pg/ml or less thereafter. Plasma BK levels in patients with SAH were higher than those in the control group, but there was no statistically significant change over time. From the measurement of FPA it was apparent that the coagulation system in the subarachnoid space is strongly activated in the early stage of SAH. The formation of BK in CSF after SAH is thought to be due to the contact activation of Hageman factor (intrinsic factor) in the subarachnoid space. Trabeculae as collagen bundles in the subarachnoid space were considered to have a possible role in activating the Hageman factor of the coagulation system in SAH.

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.

Antifibrinolytics in aneurysmal subarachnoid haemorrhage. A retrospective comparison of two different forms of antifibrinolytic therapy

The results of two different antifibrinolytic therapeutic modalities (A = AMCA 3 gm daily + Aprotinin, 3-400000 K.I.U. daily, B = AMCA, 6 gm daily) were compared retrospectively in a series of 137 patients harbouring recently ruptured intracranial aneurysms. The rates for rebleeding and thromboembolic complications were similar in both differently treated groups of patients, whilst that for ischaemic complications was significantly (p less than 0.025) lower in cases managed with modality A. In these also the incidence of hydrocephalus was decreased, although not significantly (0.20 greater than p greater than 0.19). According to these data, low-dose AMCA + Aprotinin seems to be a rational therapeutic combination for cases of ruptured intracranial aneurysms, in which antifibrinolytics are indicated.

Enkephalinase inhibition relieves pain syndromes of central dysnociception (migraine and related headache)

Normotensive and hypertensive headache sufferers were treated with D-phenylalanine, aprotinin or captopril--all inhibitors of endogenous opioid degradation. Inconsistent results were obtained using D-phenylalanine and aprotinin (acute administration at the start of a migraine attack). Satisfactory results were obtained by prophylactic treatment with captopril (an inhibitor of the angiotensin converting enzyme and of the dipeptidyl carboxypeptidase--an enkephalin inactivating enzyme) compared with conventional drugs such as methysergide, lisuride, pizotifen, clonidine and beta-blocking agents. Excellent results were obtained with captopril on patients suffering from headache and arterial hypertension who had experienced no relief from beta-blocking agents and clonidine. Captopril could thus be a drug of choice in the therapy of headache associated with essential hypertension.

Significance of vasospasm in the treatment of ruptured intracranial aneurysms

The authors have analyzed a total of 96 consecutive cases in which vasospasm followed subarachnoid hemorrhage (SAH). The SAH was caused by ruptured intracranial aneurysm or developed after aneurysm surgery. Usually at least 4 days elapsed between SAH and the onset of vasospasm. Vasospasm subsided an average of 2 weeks after onset. Of 68 patients with preoperative vasospasm, eight died due to cerebral edema resulting from ischemia, and 49% of survivors had neurological deficits. Preoperative vasospasm was not aggravated by surgical intervention when operations were carried out more than 7 days after the onset of vasospasm. Postoperative vasospasm was found in 25 of 52 patients who underwent operation within 1 week after SAH (excluding cases in Grade V). Five of these patients died, all of whom underwent surgery between the fourth and seventh day after SAH (the day of SAH was counted as the first day). There were no deaths among 20 patients operated on within the first 3 days after SAH. Postoperative vasospasm was always mild in these cases, when it occurred, probably because blood clot or blood-stained cerebrospinal fluid was removed by operative procedures. In all cases, 4 to 11 days elapsed between the last SAH and the onset of postoperative vasospasm regardless of the timing of surgery.

The effect of a simulated subarachnoid hemorrhage on cerebral blood flow in the monkey

The hydrogen clearance method was used to measure local and total cerebral blood flow (CBF) in the rhesus monkey before and for five hours after a simulated subarachnoid hemorrhage (SAH). CBF remained stable after SAH unless SAH was associated with a fall in cerebral perfusion pressure. In addition, cerebrovascular resistance did not increase after SAH. These results suggest that vasoactive agents in fresh whole blood, and the arterial spasm they produce when added to cerebrospinal fluid (CSF), play only a limited role in the pathogenesis of ischemic encephalopathy that follows an SAH.

Preoperative management of patients with ruptured intracranial aneurysms

✓ The authors report their experience with the use of an antifibrinolytic agent and hypotensive drugs in the prevention of rebleeding from recently ruptured intracranial aneurysms and conclude that both measures are of suggestive value. With further refinement in these techniques an additional reduction of early rebleeding may be expected. Secondary cerebral vasospasm remains the major obstacle to early recovery and definitive surgery for ruptured intracranial aneurysms.