Clot Evacuation

The amount of blood in the basal cisterns is one of the most consistent predictors of posthemor-rhagic vasospasm (see Chapter 3 for further details). Therefore, one of the earliest hypothesized strategies for prevention of vasospasm was to remove the subarachnoid blood to evacuate the putative spasmogenic substrate. The first report of using intracisternal fibrinolytics [recombinant tissue plasminogen activator (rtPA)] to evacuate subarachnoid blood was an observational study of 15 patients, 14 of whom had complete or partial cisternal clot clearing [by computed tomography (CT) scan]. The patient who did not have a clear clot was the only one to experience symptomatic vasospasm (24). The same authors provided the first multicentered, randomized, blinded, placebo-controlled trial of the role of intracisternal fibrinolytics (25) . Studying 100 patients, they reported, contrary to earlier reports, that the overall incidence of angiographic vasospasm was similar between the two groups (74.4% in placebo vs. 64.6% in treated). When only those patients with thick clots were considered, the authors reported a 56% RR reduction in the incidence of severe vasospasm in the treated group ( p <0.05). Other clinically important trends in the rtPA-treated group (that did not reach statistical significance) include reduced delayed neurologic worsening, a lower 14-day mortality rate, and improved three-month outcome rate. The major limitation of this study, as the authors themselves suggest, is that they largely focused on radiographic endpoints rather than clinical endpoints.

A prospective, randomized trial of coil embolization followed by intrathecal urokinase infusion in 110 patients reported symptomatic vasospasm in 9.4% of treated and 28.1% of untreated subjects ( p =0.012) and improved outcomes in the treated groups (90.6%), compared to the untreated group (75.4%; p =0.036), but no significant difference in mortality between the groups (3.8% vs. 5.3%, respectively). The authors therefore reported a benefit of fibrinolysis, resulting in a lower rate of permanent neurologic deficits, despite no difference in mortality (26). This latest study highlights the need for further investigation of the role of fibrinolytics in SAH to prevent vasospasm and its sequelae.

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