Postoperative intrathecal irrigation with plasminogen activator (Urokinase) after early stage operation on ruptured cerebral aneurysm

Abstract

In attempt to prevent angiospasm following early operation of ruptured aneurysm, intrathecal irrigation with plasminogen activator (Urokinase; UK) solution which may promote dissolution and washing-out of subarachnoid perivascular clot was employed. Clinical application was preceded and supported by the experimental survey in dogs with induced subarachnoid hemorrhage (SAH). This method was applied to all cases of early operation performed from November 1980 to March 1982, accompanied with other treatments such as systemic corticosteroids in all cases, external decompression and systemic UK in most cases, and induced hypertension in a few cases. Continuous irrigation with UK solution was started on the second postoperative day and carried out for 2 to 13 days, 8.3 days in average. 500 to 2, 500 ml of irrigation fluid containing 12 to 36 U/ml of UK was used daily. In many cases, the postoperative clinical course was much better than expected from the preoperative neurological status and CT findings. In cases of severe SAH, rapid disappearance of the clot in the basal cisterns was frequently recognized in postoperative sequential CT scans. Washing-out of the clot in the contralateral insular cistern was, however, slower and incomplete. The outcome of the 27 cases, which consisted of 2 cases of preoperative Grade I (after Hunt & Hess), 13 cases of Grade II, 7 cases of Grade III, and 5 cases of Grade IV, were as follows. Fifteen patients showed full recovery. Four returned to their work with partial restriction. Two stayed home without nursing. Three needed further nursing but were not vegetative. Three died. No undesirable reaction of the central nervous system was observed throughout the procedure. Only one case of severe meningitis was experienced. With further modification of the dose and the UK concentration in the irrigation fluid and of the adjunctive treatments, this method will become more effective.