Liu Collin, Wroe William W, Zeineddine Hussein A, Dawes Bryden, Giordano Michael, McCabe Aaron, Chen Ching-Jen, McBride Devin W, Gusdon Aaron M, Choi Huimahn A, Blackburn Spiros L
Department of Neurosurgery, The University of Texas Health Science Center at Houston, 6400 Fannin Street, Suite 2800, Houston, TX, 77030, USA.
Minnetronix Medical, St. Paul, MN, USA.
Acta Neurochir (Wien). 2025 Jul 24;167(1):202. doi: 10.1007/s00701-025-06614-4.
Free hemoglobin's release into CSF from blood breakdown is a primary instigator of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Early clearance of subarachnoid blood with intrathecal (IT) fibrinolytics has shown potential to decrease incidence of DCI. However, the dosage of fibrinolytic needed is not known. We investigated the ability of low dose tissue plasminogen activator (tPA) to rapidly remove subarachnoid clot.
We performed a single center retrospective review of aSAH patients who received IT tPA. Dosing consistent with the CLEAR III trial for IVH was utilized-tPA (1 mg) administered every 8 h via an external ventricular drain (EVD) for up to three doses. CT imaging was obtained before initiation and after the final dose. Subarachnoid clot was quantified using the Hijdra score on initial and follow-up scans. The IT tPA group was compared to a large retrospective cohort without IT tPA.
Eight aSAH patients received IT tPA treatment for the purpose of increasing blood removal after aSAH. CT imaging indicated that the Hijdra Score had a 70-100% reduction in all patients in the first 4 days with a mean 81.6% reduction compared to 41.3% reduction in a prior natural history cohort, p = 0.001. No ventriculitis or hemorrhagic complications were observed the treatment group. Clinical DCI and radiographic vasospasm was observed in two of the patients.
Low dose IT tPA delivered through an EVD after aSAH is sufficient to rapidly increase CSF blood clearance on CT imaging.
血液分解后游离血红蛋白释放至脑脊液是动脉瘤性蛛网膜下腔出血（aSAH）后迟发性脑缺血（DCI）的主要诱因。鞘内（IT）使用纤溶药物早期清除蛛网膜下腔血液已显示出降低DCI发生率的潜力。然而，所需纤溶药物的剂量尚不清楚。我们研究了低剂量组织型纤溶酶原激活剂（tPA）快速清除蛛网膜下腔血凝块的能力。
我们对接受IT tPA治疗的aSAH患者进行了单中心回顾性研究。采用与CLEAR III试验中治疗脑室内出血一致的给药方案——通过外置脑室引流管（EVD）每8小时给予tPA（1 mg），最多给予三剂。在开始给药前和最后一剂给药后进行CT成像。使用Hijdra评分对初始扫描和随访扫描中的蛛网膜下腔血凝块进行定量。将IT tPA组与未接受IT tPA的大型回顾性队列进行比较。
8例aSAH患者接受IT tPA治疗以增加aSAH后的血液清除。CT成像显示，所有患者在最初4天内Hijdra评分降低了70% - 100%，平均降低81.6%，而之前自然病程队列的降低率为41.3%，p = 0.001。治疗组未观察到脑室炎或出血并发症。2例患者出现临床DCI和影像学血管痉挛。
aSAH后通过EVD给予低剂量IT tPA足以在CT成像上迅速增加脑脊液血液清除率。
