Combined cisternal drainage and intrathecal urokinase injection therapy for prevention of vasospasm in patients with aneurysmal subarachnoid hemorrhage.

The effect of cisternal drainage and intrathecal urokinase injection in preventing symptomatic vasospasm (SVS) after aneurysmal subarachnoid hemorrhage was studied in 60 patients with uniform background (Hunt & Kosnik grade III, younger than 70 yrs, undergoing surgery within 72 hrs after hemorrhage). The incidence of permanent neurological deficits caused by vasospasm was 5/16 without cisternal drainage, 5/34 with drainage alone, and 1/10 with drainage and urokinase injection. Analysis of patients without postoperative cisternal drainage showed the amount of subarachnoid clot on the initial computed tomographic scan was closely related to the occurrence of SVS (p < 0.05, unpaired t test). Analysis of patients with cisternal drainage showed the amount of bloody cerebrospinal fluid (CSF) drained during the 10 days after surgery and the duration of drainage placement were critical in preventing vasospasm (p < 0.05, unpaired t test). Greater CSF drainage significantly reduced the incidence of permanent neurological deficits caused by vasospasm (p < 0.01, chi 2), but significantly increased the incidence of hydrocephalus requiring shunt procedures (p < 0.01, chi 2). Urokinase injection via cisternal drainage achieved a further reduction in the occurrence of SVS. Intrathecal thrombolytic therapy after aneurysmal surgery is an effective method for SVS prophylaxis, and CSF drainage (> 1500 ml for 10 days) enhances the effect.