title: Prevention of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage by intraoperative cisternal fibrinolysis using tissue-type plasminogen activator combined with continuous cisternal drainage.
abstract: The efficacy of intraoperative cisternal irrigation using tissue-type plasminogen activator (tPA) combined with continuous cisternal drainage was assessed for the prevention of symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). Seventy consecutive patients underwent direct surgery for aneurysm clipping within 48 hours of SAH and had computed tomography (CT) findings classified as Fisher group III or IV with densities of more than 65 Hounsfield units (HU). Fibrinolysis of the cisternal clots was performed during surgery using 1.6 mg tPA in 55 cases or 3.2 mg tPA in 15 cases. If postoperative CT within 24 hours of surgery showed areas with density more than 65 HU, additional tPA (0.8 mg/day) was administered into the cisternal catheter until the high density areas disappeared. The cisternal drainage catheters were left in place until day 14. Additional tPA injection was necessary in four of the 55 patients receiving 1.6 mg tPA. Symptomatic vasospasm occurred in three patients (4.3%) and two patients had low density areas on CT. Permanent deficit (hemiparesis) due to cerebral vasospasm remained in only one patient. Intraoperative cisternal irrigation with tPA combined with cisternal drainage is safe and effective for the prevention of symptomatic vasospasm following SAH.
authors.affiliation: Department of Neurosurgery, Akita University School of Medicine, Akita, Japan. kinouchi@nsg.med.akita-u.ac.jp
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Kinouchi
authors.forename: Kuniaki
authors.initials: K
authors.lastname: Ogasawara
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Shimizu
authors.forename: Kazuo
authors.initials: K
authors.lastname: Mizoi
authors.forename: Takashi
authors.initials: T
authors.lastname: Yoshimoto
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000150:complications*; D002946:Cisterna Magna; D004322:Drainage; D005260:Female; D005342:Fibrinolysis; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013345:Subarachnoid Hemorrhage / Q000209:etiology* / Q000628:therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014057:Tomography, X-Ray Computed; D020301:Vasospasm, Intracranial / Q000000981:diagnostic imaging / Q000517:prevention & control*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator