Cisternal irrigation therapy with urokinase and ascorbic acid for prevention of vasospasm after aneurysmal subarachnoid hemorrhage. Outcome in 217 patients.
BACKGROUND
Cisternal irrigation therapy with urokinase and ascorbic acid was introduced to prevent symptomatic vasospasm after aneurysmal subarachnoid hemorrhage (SAH). To dissolve and wash out the subarachnoid clot, cisternal irrigation with urokinase is used. Ascorbic acid is added to degenerate oxy-hemoglobin, one of the strongest spasmogenic substances, into verdohemelike products, which are nonspasmogenic. The efficacy and safety of this therapy were evaluated.


METHODS
This therapy was performed consecutively in 217 patients. The degree of SAH of the patients was classified as Fisher CT Group 3, and the highest CT number (Hounsfield number) exceeded 60 in the SAH, which suggested a significant risk for symptomatic vasospasm. All patients underwent surgery within 72 hours from the onset of SAH. After clipping the aneurysm, irrigation tubes were placed in the Sylvian fissure (inlet) unilaterally or bilaterally and in the prepontine or chiasmal cistern (outlet). Lactated Ringer's solution with urokinase (120 IU/mL) and ascorbic acid (4 mg/mL) was infused at a rate of 30 mL/hour/side for approximately 10 days.


RESULTS
Of the 217 patients studied, symptomatic vasospasm was observed in 6 cases (2.8%), and two of these six cases (0.9%) demonstrated sequelae. The average total blood volume calculated from the drainage fluid was approximately 114 mL. Analysis of the absorption spectrum of the drainage fluid revealed disappearance of the oxy-hemoglobin-specific 576-nm peak. Complications occurred in eight patients during irrigation therapy; two patients experienced seizures, two patients developed meningitis, and four patients had an intracranial hemorrhage. However, all of these patients recovered without neurological deficits.


CONCLUSIONS
These results suggest that cisternal irrigation therapy with urokinase and ascorbic acid is effective in preventing symptomatic vasospasm after aneurysmal SAH.
Kodama
N
N
Department of Neurosurgery, Fukushima Medical School, Japan.
Sasaki
T
T
Kawakami
M
M
Sato
M
M
Asari
J
J
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001205:Ascorbic Acid / Q000008:administration & dosage*; D002946:Cisterna Magna / Q000000981:diagnostic imaging; D002985:Clinical Protocols; D005260:Female; D016166:Free Radical Scavengers / Q000008:administration & dosage*; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D008297:Male; D008875:Middle Aged; D010108:Oxyhemoglobins / Q000187:drug effects; D010960:Plasminogen Activators / Q000008:administration & dosage*; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D013345:Subarachnoid Hemorrhage / Q000150:complications* / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology; D016284:Technetium Tc 99m Pentetate; D007507:Therapeutic Irrigation / Q000379:methods; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014568:Urokinase-Type Plasminogen Activator / Q000008:administration & dosage*; D020301:Vasospasm, Intracranial / Q000209:etiology / Q000517:prevention & control*
D016166:Free Radical Scavengers; D010108:Oxyhemoglobins; D019275:Radiopharmaceuticals; D010960:Plasminogen Activators; D014568:Urokinase-Type Plasminogen Activator; D001205:Ascorbic Acid; D016284:Technetium Tc 99m Pentetate