Article Text


Antifibrinolytics for the initial management of sub arachnoid haemorrhage
  1. Simon Carley, Locum Consultant in Emergency Medicine,
  2. Ayan Sen, Clinical Fellow


    A short cut review was carried out to gather the evidence for and against the use of tranexamic acid to patients who have suffered subarachnoid bleeding. 267 papers were found using the reported search, of which one presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of this best paper are tabulated. A clinical bottom line is stated.

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    Report by Simon Carley, Locum Consultant in Emergency MedicineChecked by Ayan Sen, Clinical Fellow

    Clinical scenario

    A 24 year old man presents to the emergency department following a sudden headache and collapse. He is GCS 14 on arrival with no localising signs. CT scan demonstrates a sub arachnoid haemorrhage. In a previous hospital you were advised to give tranexamic acid to prevent rebleeding. You suggest this to the neurosurgical SpR on call who thinks you are talking rubbish and strongly advises against it.

    You wonder if he is an evidence based neurosurgeon … or whether he is behind the times?

    Three part question

    [In patients with confirmed SAH] are [antifibrinolytics better than placebo] at [reducing rebleeding, improving survival, or improving morbidity]

    Search strategy

    Medline 1966-12/04 using the Ovid interface. The Cochrane Library Issue 4, 2004.

    Medline: [exp Subarachnoid Hemorrhage/OR subarachnoid OR exp Aneurysm, Ruptured/OR] AND [exp Antifibrinolytic Agents/OR OR exp Tranexamic Acid/OR tranexamic OR exp Aminocaproic Acids/OR aminocaproic OR exp 6-Aminocaproic Acid/OR epsilon aminocaproic OR epsilon amino-caproic OR antifibrinolytic$.mp]

    Cochrane: subarachnoid hemorrhage OR subarachnoid haemorrhage.

    Search outcome

    Altogether 267 references found including one recent Cochrane review. No papers after the publication of the Cochrane review were found. The summary of the Cochrane review is presented here.


    A well constructed review article answers the question. Although there appears to be a reduction in the rate of rebleeding this is not matched by an improvement in patient outcome. The authors of this review postulate that the increase in cerebral ischaemia seen in most of the trials may account for this.

    From a clinical perspective there appears to be little to be gained from the administration of antithrombolytics in confirmed SAH.


    Antithrombolytics are not indicated in the emergency management of sub-arachnoid haemorrhage.

    Report by Simon Carley, Locum Consultant in Emergency MedicineChecked by Ayan Sen, Clinical Fellow


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