J Korean Neurosurg Soc.  2021 Mar;64(2):207-216. 10.3340/jkns.2020.0154.

The Effect of Locally Administered Fibrinolytic Drugs Following Aneurysmal Subarachnoid Hemorrhage : A Meta-Analysis with Eight Randomized Controlled Studies

• Jang KM
• Choi HH
• Nam TK
• Park YS
• Kwon JT
• Byun JS
• Hwang D

• KMID: 2513851
• DOI: http://doi.org/10.3340/jkns.2020.0154

Abstract

Objective
: Rapid dissolution of blood clots reduces vasospasm and hydrocephalus after subarachnoid hemorrhage (SAH), and locally administered fibrinolytic drugs (LAFDs) could facilitate the dissolution. However, the efficacy of LAFDs remains controversial. The aim of this meta-analysis was to determine the efficacy of LAFDs for vasospasm and hydrocephalus and in clinical outcomes.
Methods
: From PubMed, EMBASE, and Cochrane database, data were extracted by two authors. Meta-analysis was performed using a random effect model. Inclusion criteria were patients who had LAFDs with urokinase-type or recombinant tissue-plasminogen activator after SAH in comparison with medically untreated patients with fibrinolytic drugs. We only included randomized controlled trials (RCTs) in this analysis. The outcomes of interest were vasospasm, hydrocephalus, mortality, and 90-day unfavorable functional outcome.
Results
: Data from eight RCTs with 550 patients were included. Pooled-analysis revealed that the LAFDs were significantly associated with lower rates of vasospasm (LAFDs group vs. control group, 26.5% vs. 39.2%; odds ratio [OR], 0.48; 95% confidence interval [CI], 0.32–0.73); hydrocephalus (LAFDs group vs. control group, 26.0% vs. 31.6%; OR, 0.54; 95% CI, 0.32–0.91); and mortality (LAFDs group vs. control group, 10.5% vs. 15.7%; OR, 0.58; 95% CI, 0.34–0.99). The proportion of 90-day unfavorable outcomes was lower in the LAFDs group (LAFDs group vs. control group, 32.7% vs. 43.5%; OR, 0.55; 95% CI, 0.37–0.80).
Conclusion
: This meta-analysis with eight RCTs indicated that LAFDs were significantly associated with lower rates of vasospasm and hydrocephalus after SAH. Thus, LAFDs could consequently reduce mortality and improve clinical outcome after SAH.

Keyword

Subarachnoid hemorrhage; Fibrinolytic agents; Plasminogen activators; Vasospasm, Intracranial; Hydrocephalus

Figure

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  Fig. 1. Flow diagram for the selection of relevant studies.

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  Fig. 2. Risk of bias (RoB) summary: review authors’ judgments about each RoB item for each included study.

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  Fig. 3. Efficacy of locally administered fibrinolytic drugs in the prevention of outcomes. Tests for heterogeneity are described using I2 and p value. A : Vasospasm. B : Hydrocephalus. C : Mortality. D : Unfavorable clinical outcome at 90 days. OR : odds ratio, CI : confidence interval.

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  Fig. 4. Subgroup analysis : comparison of the efficacy of locally administered fibrinolytic drugs with respect to type and route of delivery. Interaction p<0.05 indicates significant difference between the two groups. A : Vasospasm, hydrocephalus. B : Mortality, unfavorable outcome. CI : confidence interval, rt-PA : recombinant-type plasminogen activator, UK : urokinase-type plasminogen activator, EVD : extraventricular drainage

Reference

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