Intracisternal recombinant tissue plasminogen activator after aneurysmal subarachnoid hemorrhage

Abstract

Fifteen patients undergoing surgery within 48 hours of aneurysm rupture were administered recombinant tissue plasminogen activator (rt-PA) directly into the basal subarachnoid cisterns after minimal surgical clot removal and aneurysm clipping. Preoperatively, 13 patients had diffuse or localized thick subarachnoid blood clots on computerized tomography (CT), and two had diffuse thin clots. The rt-PA was given as a single intraoperative injection of 7.5 mg (one patient), 10 mg (nine patients), or 15 mg (five patients). Postoperative cisternal drainage was employed in three patients. All patients except one demonstrated partial to complete cisternal clot clearance on CT scans within 24 hours after surgery. The patient who showed no clot reduction was the only patient in this series to develop symptomatic vasospasm and was the only fatality, dying 8 days after rupture. No vasospasm was seen on follow-up cerebral angiography in six of the 14 responding patients, and mild-to-moderate arterial narrowing was seen in at least one major cerebral artery in the remaining eight patients. Severe angiographic vasospasm was not seen, although the patient who died did not undergo repeat angiography. There was one major complication early in the series which seemed clearly related to treatment, and that was a large extradural hematoma occurring within several hours of craniotomy. Intrathecal fibrinolytic treatment appears effective in clearing subarachnoid clot and reducing vasospasm, and may be associated with acceptable risks if given to patients with large-volume subarachnoid hemorrhages at high risk for severe vasospasm.

Milrinone Reduces Cerebral Vasospasm After Subarachnoid Hemorrhage of WFNS Grade IV or V

“…22) Tissue plasminogen activator has also been used. 7,8,18,23) Irrigation solution contains urokinase to dissolve and eliminate the subarachnoid clot, and ascorbic acid to act as an antioxidant to convert some spasmogens to harmless, verdoheme-like substances. 12,14) Treatment of patients with thick SAH by ordinary cisternal irrigation has failed to prevent symptomatic vasospasm or angiographical spasm.…”

Prevention of spinal epidural fibrosis by recombinant tissue plasminogen activator in rats

“…3 Thrombolytic drugs have been widely used for thromboembolic disease and preventing vasospasm caused by subarachnoid haemorrhage. 7,8,14 It is stated that fibrinolytic treatment in subarachnoid haemorrhage in man appears effective, and may be associated with acceptable risks. 7,8 Although there was a risk of epidural bleeding with perisurgical epidural use of rt-PA, only one episode of epidural bleeding occurred in rt-PA The rats utilised in this study demonstrate reliable formation of postlaminectomy peridural fibrosis at 6 weeks following laminectomy.…”

“…7,8,14 It is stated that fibrinolytic treatment in subarachnoid haemorrhage in man appears effective, and may be associated with acceptable risks. 7,8 Although there was a risk of epidural bleeding with perisurgical epidural use of rt-PA, only one episode of epidural bleeding occurred in rt-PA The rats utilised in this study demonstrate reliable formation of postlaminectomy peridural fibrosis at 6 weeks following laminectomy. The application of rt-PA demonstrated a clear reduction in the degree of epidural fibrosis when compared with control group in total score (P ¼ 0.001), in intermuscular scar score (P ¼ 0.04), in middle scar score (P ¼ 0.001), in deep scar score (P ¼ 0.001), in dural adhesion score (P ¼ 0.01) and finally in arachnoiditis (P ¼ 0.01).…”

“…The dose of rt-PA chosen for this study was 0.25 mg and was based on the published data in the literature. 7,8 In the second group, all procedures were done in a similar fashion but without the insertion of any medication. The rats were followed-up in a temperaturecontrolled room for 6 weeks.…”

Comparative Preventive Efficacy of Recombinant Tissue Plasminogen Activator (rt-PA), Urokinase, Hyaluronic acid and Enoxaparin in Post Laminectomy Epidural Fibrosis in Rats

“…The dose of rt-PA chosen for this study was 0.25 mg. The chosen dose of rt-PA for this study was based on the published knowledge in the literature (6,7). In the fourth group all interventional procedures were done in a similar fashion and enoxaparine (Clexane R 10 mg/0.1 ml amp, Eczacibasi, Istanbul, Turkey; 1.5 mg/kg) was inserted beneath and over the dura mater at laminectomy area.…”