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Intraventricular Tissue Plasminogen Activator for the Prevention of Vasospasm and Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

Ramakrishna, Rohan MD; Sekhar, Laligam N. MD, FACS; Ramanathan, Dinesh MD; Temkin, Nancy PhD; Hallam, Danial MD; Ghodke, Basavaraj V. MD; Kim, Louis J. MD

doi: 10.1227/01.NEU.0000370920.44359.91
Clinical Studies

BACKGROUND: The sequelae of aneurysmal subarachnoid hemorrhage (SAH) include vasospasm and hydrocephalus.

OBJECTIVE: To assess whether intraventricular tissue plasminogen activator (tPA) results in less vasospasm, fewer angioplasties, or fewer cerebrospinal fluid shunting procedures.

METHODS: 41 patients (tPA group, Hunt and Hess 3, 4, 5) from 2007 to 2008 received intraventricular tPA and lumbar drainage for a minimum of 5 days (range 5–7 days) and were compared to a matched group of 35 patients from 2006 to 2007 (Control, HH 3, 4, 5). Statistical comparison was done by t test analysis or Fisher exact tests and data are expressed as average ± standard error of the mean.

RESULTS: There were no significant differences in demographic data, although the tPA group had a trend toward more surgical patients. The tPA group of patients had a significantly higher modified Fisher grade than controls (P < .001) and had a significantly better Hunt and Hess grade than controls (P < .03). The angioplasty rate was significantly lower among the tPA patients (15.0% ± 5.6) than controls (40.0% ± 8.5, P = .019). The number of days spent in severe vasospasm normalized over the 14-day monitoring period by transcranial Doppler was significantly lower in the tPA group (0.09 ± 0.02) than controls (0.17 ± 0.03). The shunt rate was significantly lower among tPA patients (17.5% ± 6.0) than controls (42.8% ± 8.6). There were 2 clinically silent tract hemorrhages in the tPA group (4.8%).

CONCLUSION: Intraventricular tPA is a safe and effective treatment for reducing both angioplasty and shunting rates in patients with SAH H&H Grades 3 to 5. A randomized trial is indicated.

Departments of Neurological Surgery and Radiology, Harborview Medical Center, University of Washington Medical Center, Seattle, Washington

Reprint requests: Laligam N. Sekhar, MD, FACS, Departments of Neurological Surgery and Radiology, Harborview Medical Center, University of Washington School of Medicine, 325 9th Ave., Seattle, WA 98104.

Received, March 30, 2009.

Accepted, September 25, 2009.

Copyright © by the Congress of Neurological Surgeons