Antifibrinolytic therapy in the treatment of aneurysmal subarachnoid hemorrhage.

At the present time, there remains considerable uncertainty regarding the safety and efficacy of antifibrinolytic therapy in the treatment of aneurysmal SAH. Furthermore, there is little to guide us on precisely how to employ the agents. Whether to continue to use antifibrinolytic therapy after considering the results of the 1984 Cooperative Aneurysm Study trial and the Glasgow-Rotterdam-Amsterdam-London trial remains very much a philosophical decision. However, rebleeding is instantly and permanently devastating and 70% fatal, while ischemic deficits from vasospasm have a gradual onset and are potentially reversible. Accordingly, our policy is to continue to use antifibrinolytic therapy in those patients in whom it is desired to delay surgery. Our feeling is that, while there is no demonstrated advantage in acute mortality in either of the previously mentioned series, hypertensive, hypervolemic therapy or calcium channel blocking agents might ameliorate the ischemic consequences of therapy. Accordingly, it is in the context of combined therapy that the reduction in rebleeding will significantly influence patient outcome.