Epsilon-aminocaproic acid and recurrent subarachnoid hemorrhage: a clinical trial

Unexpected higher blood loss associated with higher dose ε-aminocaproic acid in pediatric scoliosis surgery

The purpose of this study was to determine if a higher dosing of ε-aminocaproic acid (EACA) is associated with less perioperative blood loss than a lower dose. A total of 74 patients having scoliosis surgery were analyzed. Of the 74 patients, 36 patients received EACA (10 mg/kg/h) and 38 patients received EACA (33 mg/kg/h). After controlling for key variables, an infusion of 33 mg/kg/h of EACA was associated with an increase in intraoperative blood loss of 8.1 ml/kg compared with an infusion of 10 mg/kg/h of EACA. A 33 mg/kg/h intraoperative infusion is associated with higher intraoperative blood loss than an infusion at 10 mg/kg/h.

Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage

BACKGROUND

Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably related to dissolution of the blood clot at the site of aneurysm rupture by natural fibrinolytic activity. This review is an update of a previously published Cochrane review.

OBJECTIVES

To assess the effects of antifibrinolytic treatment in people with aneurysmal subarachnoid haemorrhage.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (1948 to December 2012), and EMBASE (1947 to December 2012). In an effort to identify further published, unpublished, and ongoing studies we searched reference lists and trial registers, performed forward tracking of relevant references and contacted drug companies.

SELECTION CRITERIA

Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid, or an equivalent) with control in people with subarachnoid haemorrhage of suspected or proven aneurysmal cause.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion and extracted the data. Three review authors assessed trial quality. For the primary outcome we converted the outcome scales between good and poor outcome for the analysis. We scored death from any cause and rates of rebleeding, cerebral ischaemia, and hydrocephalus per treatment group. We expressed effects as risk ratios (RR) with 95% confidence intervals (CI). We used random-effects models for all analyses.

MAIN RESULTS

We included 10 trials involving 1904 participants. The risk of bias was low in six studies. Four studies were open label and were rated as high risk of performance bias. One of these studies was also rated as high risk for attrition bias. Four trials reported on poor outcome (death, vegetative state, or severe disability) with a pooled risk ratio (RR) of 1.02 (95% confidence interval (CI) 0.91 to 1.15). All trials reported on death from all causes with a pooled RR of 1.00 (95% CI 0.85 to 1.18). In a trial that combined short-term antifibrinolytic treatment (< 72 hours) with preventative measures for cerebral ischaemia the RR for poor outcome was 0.85 (95% CI 0.64 to 1.14). Antifibrinolytic treatment reduced the risk of re-bleeding reported at the end of follow-up (RR 0.65, 95% CI 0.44 to 0.97; 78 per 1000 participants), but there was heterogeneity (I² = 62%) between the trials. The pooled RR for reported cerebral ischaemia was 1.41 (95% CI 1.04 to 1.91, 83 per 1000 participants), again with heterogeneity between the trials (I² = 52%). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus in five trials (RR 1.11, 95% CI 0.90 to 1.36).

AUTHORS' CONCLUSIONS

The current evidence does not support the use of antifibrinolytic drugs in the treatment of people with aneurysmal subarachnoid haemorrhage, even in those who have concomitant treatment strategies to prevent cerebral ischaemia. Results on short-term treatment are promising, but not conclusive. Further randomised trials evaluating short-term antifibrinolytic treatment are needed to evaluate its effectiveness.

Antifibrinolytic therapy in the management of aneurismal subarachnoid hemorrhage revisited. A meta-analysis

BACKGROUND

To reassess the use of antifibrinolytics (AF) in the management of aneurysmal subarachnoid hemorrhage (SAH) in the setting of present-day treatment strategies.

METHOD

The authors conducted a systematic review of the literature and a meta-analysis. They reviewed the PubMed database and conducted a manual review of article bibliographies.

RESULTS

Using a pre-specified search strategy, 17 relevant studies involving a total of 2,872 patients with SAH at baseline, from which data of 1,380 patients having received AF, were included in a meta-analysis. Pooled odds ratios of the impact of AF on functional outcomes, rebleeding, and cerebral infarction were calculated. Short-term use of AF (72 h or less) associated with medical prevention of ischemic deficit seems to yield better results on functional outcome than long-term use of AF, especially if not associated with a medical prevention of ischemic deficit. The risk of cerebral infarction is not increased by the short-term use of AF and the risk of rebleeding is decreased independently of the length of AF use.

CONCLUSIONS

The use of AF should be reconsidered in the setting of modern-era treatment strategies, as the short-term use associated with medical prevention of ischemic deficit decreases the rate of rebleeding and does not increase the risk of cerebral infarction, thus potentially yielding better protection against poor functional outcome.

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.

Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage

BACKGROUND

Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably due to dissolution of the clot by natural fibrinolytic activity.

OBJECTIVES

The objective of this review was to assess the effect of antifibrinolytic treatment in patients with aneurysmal subarachnoid haemorrhage.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register, the Cochrane Controlled Trials Register, Medline and Embase (last searched June 2002) and reference lists of articles. We also contacted drug companies.

SELECTION CRITERIA

Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid or an equivalent) with control in people with confirmed subarachnoid haemorrhage.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion and extracted the data. All five reviewers assessed trial quality.

MAIN RESULTS

Nine trials involving 1399 patients were included. Based on 1041 patients in three trials, antifibrinolytic treatment did not show any evidence of benefit for poor outcome (death, vegetative state or severe disability) with an odds ratio of 1.12, 95% confidence interval 0.88 to 1.43. Death from all causes was not significantly influenced by treatment across all nine trials (odds ratio 0.99, 95% confidence interval 0.79 to 1.24). Antifibrinolytic treatment reduced the risk of re-bleeding reported at the end of follow-up, with some heterogeneity between the trials (odds ratio 0.55, 95% confidence interval 0.42 to 0.71). Treatment increased the risk of cerebral ischaemia in five trials (odds ratio 1.39, 95% confidence interval 1.07 to 1.82) with considerable heterogeneity between the most recent study (Roos 2000), in which specific treatments to prevent cerebral ischemia were used, and the four older studies. Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus in five trials (odds ratio 1.14, 95% confidence interval 0.86 to 1.51).

REVIEWER'S CONCLUSIONS

Treatment does not improve clinical outcome because the benefit is offset by an increase in poor outcome caused by cerebral ischemia as a result of treatment with antifibrinolytics. These data do not support the routine use of antifibrinolytic drugs in the treatment of patients with aneurysmal subarachnoid haemorrhage.

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.

Fibrinolytic activity after subarachnoid haemorrhage and the effect of tranexamic acid

Seventy-four patients with recent subarachnoid haemorrhage were randomly allocated to placebo or tranexamic acid treatment. Fibrinolytic activity in the blood and cerebrospinal fluid was assessed before treatment, one week later and two weeks later. The natural history of fibrinolysis following subarachnoid haemorrhage was obtained from analysis of the placebo group. Following subarachnoid haemorrhage, fibrin degradation products and plasminogen activity in the cerebrospinal fluid were elevated. Subsequently, fibrin degradation products in the cerebrospinal fluid fell progressively over the following 2 weeks. Changes in cerebrospinal fluid plasminogen activity correlated with those of blood plasminogen activity. Complications such as rebleeding, hydrocephalus or cerebral thrombosis could not be predicted from analysis of fibrinolytic activity. Tranexamic acid treatment resulted in a reduction in cerebrospinal fluid and blood plasminogen activity. The relevance of fibrinolysis in cerebrospinal fluid and blood to the management of subarachnoid haemorrhage is discussed.

Benefits and risks of antifibrinolytic therapy in the management of ruptured intracranial aneurysms. A double-blind placebo-controlled study

One hundred patients with a verified subarachnoid haemorrhage were studied in a double blind, placebo-controlled trial at a single centre to determine the value and relative risks of tranexamic acid (TXA) in the management of ruptured intracranial aneurysms. The incidence of recurrent haemorrhage between active and placebo groups was identical (12%) and the mortality from recurrent haemorrhage was 7% and 5%, respectively. The overall incidence of cerebral infarction before surgery, at discharge and at 6 months follow-up was greater in the TXA group (27%) than in the control group (11%). Post-operative cerebral ischaemia was significantly more frequent in the active, 18 of 29 as compared to 6 of 32 patients, in the placebo group. In a fifth of the patients in whom cerebral blood flow was estimated there was a significant reduction of cerebral blood flow (CBF) on the side of the ruptured aneurysm in the TXA treated group. It is suggested that this may be the cause of the increased incidence of cerebral ischaemia in this group. There was no significant difference in the incidence of cerebral vasospasm, hydrocephalus, visual disturbances and gastrointestinal disturbances. More fatalities were encountered from ischaemia and recurrent haemorrhage in the TXA group but these differences did not reach statistical significance at the 5% level. Given that disability was due to either vasospasm or recurrent haemorrhage than a patient under TXA treatment was significantly more likely to have disability due to vasospasm (p less than 0.04); the reverse was true for the placebo patient (p less than 0.05).

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.

Recurrent aneurysmal subarachnoid haemorrhage: incidence, timing and effects. A re-appraisal in a surgical series

A series of 510 patients with proven aneurysmal subarachnoid haemorrhage (SAH) is reported. The incidence of recurrent haemorrhage during the period awaiting surgery was 13.7%. There was no significant difference in incidence between good and poor grade patients. Following rebleeding there was an immediate mortality of 34% in good grade patients and 52% in poor grade patients. In the long term only 44.4% of good grade and 8% of poor grade patients made a good recovery following a second bleed as compared to 70.6% and 52.8% respectively for those who did not rehaemorrhage.

Antifibrinolytic agents in subarachnoid haemorrhage

For many years clinicians have used antifibrinolytic agents to try to reduce rebleeding after subarachnoid haemorrhage. Early studies of their effectiveness produced conflicting results. This paper re-evaluates the available trials and considers benefits in the light of potential complications. Present evidence conclusively demonstrates that epsilon-aminocaproic acid and tranexamic acid administered in standard dosage, reduce the risk of rebleeding but, as a result of an increased incidence of ischaemic complications, do not benefit patients' outcome.

Overall results in 304 consecutive patients with acute spontaneous subarachnoid hemorrhage

The results obtained in 304 consecutive patients with spontaneous subarachnoid hemorrhage are described, the majority of whom (86%) were admitted while in acute condition. Only 46% of the patients in this series were in good condition at admission. The initial management was standardized for all patients, but the protocol of "delayed surgery" was applied to patients with subarachnoid hemorrhage from aneurysmal rupture. Two hundred and twenty-two patients (73%) had intracranial aneurysms. Of these, 20 (9%) were moribund and died shortly after admission; nine (4%) underwent emergency surgery due to the coexistence of a life-threatening cerebral hematoma; seven (3%) were operated upon within 3 days of admission; 78 (35%) died after rebleeding or after steady deterioration of the patient's condition due to vasospasm while awaiting surgery. Of the remaining 108 patients ready for delayed surgery, 12 (11%) (operation refused, elderly patients in poor general condition, spontaneous thrombosis of the aneurysm) were treated conservatively, and 96 (89%), who were in various clinical conditions, were actually operated on. Of these 96 patients, 79 (82%) exhibited excellent or good results, 5 (5%) were disabled, and 12 (12%) died. In the authors' experience, the overall management of intracranial aneurysms in unselected patients according to the protocol of delayed surgery results in significant loss of patients awaiting surgery, and good surgical results in the survivors.

An experimental study of the influence of antifibrinolytic therapy on post-subarachnoid-hemorrhagic cerebral vasospasm and hydrocephalus

The incidence and severity of cerebral vasospasm and hydrocephalus following induced subarachnoid hemorrhage in an experimental group of animals that subsequently received epsilon-aminocaproic acid was compared to that seen in a control group that received no antifibrinolytic therapy. No augmentation of either vasospasm or hydrocephalus could be attributed to the epsilon-aminocaproic acid in the treated as compared to the control group.

Pharmacologic management of subarachnoid hemorrhage

Subarachnoid hemorrhage, following rupture of an intracranial aneurysm, affects about 25 000 people in the U.S. each year. Less than half the patients who survive until hospital admission have an overall favorable outcome. This high morbidity and mortality rate is a result of serious complications following the initial subarachnoid hemorrhage, the most significant of these being rebleeding and cerebral ischemia secondary to vasospasm. While surgical clipping of the aneurysm is the most definitive therapy, this procedure may be postponed for a week or two after the initial hemorrhage, depending on the patient's clinical condition. Pharmacological therapy is a critical part of the preoperative care of these patients and of the postoperative management of complications. This article discusses the syndromes of rebleeding and vasospasm and reviews the current pharmacologic therapy for each.

Ruptured intracranial aneurysms: has the incidence of early rebleeding been over-estimated?

Of 110 consecutive patients with ruptured intracranial aneurysms, 49 underwent delayed neurological deterioration, involving 57 episodes in all. During the first three weeks after the presenting haemorrhage less than a third of these episodes were due to confirmed rebleeding. Rebleeding episodes were found to have a "flat" distribution in time during this period, but episodes of non-haemorrhagic deterioration "peaked" between days 4-12. This peak coincides with the peak for rebleeding which was described in earlier studies on aneurysms, and it is suggested that confusion between non-haemorrhagic deterioration and rebleeding may have led to a significant over-estimate of the incidence of early rebleeding with important implications for the optimum timing of surgical intervention.

Results and complications of surgical management of 809 intracranial aneurysms in 722 cases. Related and unrelated to grade of patient, type of aneurysm, and timing of surgery

Data from 722 consecutive causes with intracranial aneurysms were stored in a computer and later retrieved for analysis. Results and complications (including preoperative death and morbidity) of the surgical management of these patients were correlated with the Botterell grade of the patient in individuals with a recent subarachnoid hemorrhage (SAH), with the type of aneurysm, and with the timing of the surgical procedure. Patients with no SAH within 30 days prior to hospital admission were classified as "no SAH." Approximately 30% of all patients had sustained more than one hemorrhage. Death and morbidity rates prior to surgery in good-grade patients with a recent SAH exceeded the risk of surgery itself. Rebleeding was the primary cause for death and morbidity in Grade 1 patients: 3% of Grade 1 patients died from a recurrent hemorrhage and 7% deteriorated to a lower grade. Deterioration from ischemia produced by vasospasm related or unrelated to rebleeding exceeded the risks of rebleeding in Grade 2 patients. There was an operative morbidity of 2% and mortality of 2% in patients who were classified as Grade 1 at the time of surgery, but an overall management morbidity of 3% and mortality of 6% in patients who were in Grade 1 at the time of hospital admission. Early surgery in Grade 1 patients was not associated with an increased incidence of delayed ischemia postoperatively. In Grade 2 patients, the operative morbidity and mortality was 7% and 4%, respectively, and the management morbidity and mortality 16% and 11%, respectively. Early surgery in this group was associated with a high frequency of postoperative delayed ischemia (particularly in patients with more than one SAH). Epsilon-aminocaproic acid appeared to protect against a rebleed, gut was associated with a higher incidence of postoperative pulmonary emboli. Intraoperative complications were related both to the size of the aneurysm and to its location. Repair of multiple aneurysms did not adversely affect the result. The surgical approach, the importance of using a self-retaining brain retractor, and the technical complications in these cases are discussed.

The effects of epsilon aminocaproic acid on contractile properties and catecholamine content of rat carotid arteries

The prevalent use of epsilon aminocaproic acid (EACA) to prevent rebleeding in the preoperative management of ruptured intracranial aneurysms raises the question of a relationship between this drug and cerebral vasospasm. The effects of EACA on the contractile properties of the rat common carotid artery were measured in vitro, and the effects of EACA on the catecholamine content of these arteries were determined qualitatively. When carotid artery segments from rats that had been infused with lactated Ringer's solution alone were incubated in the presence of 1 mM EACA, they exhibited a decrease in contractile activity brought about by the presence of either serotonin or norepinephrine, and an increase in contractile activity when potassium chloride was used. These changes were not witnessed if the arterial segments came from rats that had been infused with lactated Ringer's solution containing EACA. No effect of epsilon aminocaproic acid was found on the median effective dose values for each vasoconstrictor used. Fluorescence histochemistry showed no qualitative changes in the catecholamine content of carotid arteries following EACA treatment.

Antifibrinolytic treatment in subarachnoid haemorrhage: present state

Two randomised controlled clinical trials in patients with recently ruptured intracranial aneurysms were undertaken using tranexamic acid (AMCA) to prevent early recurrent bleeding. In our accumulated series of 105 patients 53 were given AMCA and 52 were controls. 13% of the AMCA-treated patients and 31% of the controls rebled. In patients treated with AMCA the recurrent bleeding took place later than the rebleeding in the control patients. Vasospasm and delayed cerebral ischaemic deficits were seen more frequently in patients treated with AMCA. Total mortality from rebleeding and cerebral ischaemia was 25% in AMCA-treated patients and 19% in the controls during the six weeks' observation time. Coagulation factors remained unaffected by the drug. Local fibrinolysis in the cerebrospinal fluid decreased after one week in patients treated with AMCA. After two weeks the fibrinolytic activity was similar in AMCA-treated patients and in the controls. After experimental subarachnoid haemorrhage in 90 rabbits, AMCA was found to suppress plasminogen activator activity, mainly in the leptomeninges. This occurred however only during the first few postbleeding days. Antifibrinolytic agents only appear to reduce the risk of recurrent bleeding during the first ten day period after the primary aneurysm rupture. However they also seem to produce delayed cerebral ischaemia in patients with subarachnoid haemorrhage. Synthetic antifibrinolytics evidently shift the incidence of rebleeding curve to the right but these drugs are probably of diminished value in the subsequent weeks of risk.

Considerations in early surgery on good-risk patients with ruptured intracranial aneurysms

A retrospective analysis of 100 consecutive patients with proven ruptured intracranial aneurysms, classified as Botterell Grades I to III on admission, was carried out to evaluate the efficacy of early operation. Surgical and management mortality/morbidity rates were lower for cases in which a single hemorrhage was operated on within 48 hours than when surgery was delayed for 7 days or more. Surgical and management mortality/morbidity rates were worse in good-risk patients treated surgically between the 3rd and 7th days following a hemorrhage, reflecting the increased incidence of postoperative vasospasm and raised intracranial pressure encountered at surgery during this interval.

Comparative clinical trial of epsilon amino-caproic acid and tranexamic acid in the prevention of early recurrence of subarachnoid haemorrhage

A comparative controlled clinical trial of epsilon aminocaproic acid (EACA), 36 g/day and tranexamic acid (TEA), 6 g/day, was undertaken to assess their effectiveness in reducing early recurrence of subarachnoid haemorrhage (SAH). Of 90 patients treated with EACA recurrent haemorrhage was seen in 8% of these patients and 7% of the patients developed delayed ischaemic deficit. The total pre-operative mortality in EACA-group was 11%. Of 61 patients treated with TEA, 10% had recurrent haemorrhage and delayed ischaemic deficit occurred in 5% of the patients. The total pre-operative mortality in TEA-group was 11%. No difference was found between the effectiveness and side-effects of these drugs.

Subarachnoid hemorrhage in middle-Finland: incidence, early prognosis and indications for neurosurgical treatment

The incidence of subarachnoid hemorrhage (SAH) in Middle-Finland 1976-78 was 19.4/100,000/year. The incidence increased consistently with age. The early prognosis was similar to that in earlier studies, with 25% dying on the first day, and 49% during the first 3 months after the initial bleeding. The fatality rate decreased sharply after the bleeding: of all deaths during the first 3 months, the weekly fatality rate was 65% during the 1st week, 12% during the 2nd, and 4% during the 3rd. Thereafter the weekly fatalities up to 3 months averaged 1.6%. Only 20% of the patients of the entire series were assessed as being eligible for neurosurgical treatment. Intercurrent fatal rebleeds further reduced this number. The chances of increasing the number of SAH patients suitable for neurosurgery are discussed. The timing of surgery should be earlier than in the present study (median 15 days after the bleeding) in order to avoid frequently fatal recurrences. Vertebral angiograms should be obtained from patients with no aneurysms found by bilateral carotid angiography. The upper age limit of 60 years should be abolished. By these means the proportion of SAH patients potentially eligible for neurosurgery could be increased to about 40%.