Stereotactic Aspiration-thrombolysis of Intracerebral Hemorrhage and Its Impact on Perihematoma Brain Edema

Overview

Journal Neurocrit Care

Specialty Critical Care

Date 2008 Mar 11

PMID 18327659

Citations 24

Authors

J Ricardo Carhuapoma

Ryan J Barrett

Penelope M Keyl

Daniel F Hanley

Robert R Johnson

Affiliations

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Abstract

Background: Recent reports suggest that when thrombolytic agents are administered within the clot, lysis rate accelerates at the expense of increased risk of worsening edema. To test this hypothesis, we report on the volumetric analysis of (1) the intraparenchymal hematoma and, (2) perihematomal edema in a cohort of ICH patients treated with intraclot rtPA.

Methods: A convenience sample of highly selected ICH patients underwent frameless stereotactic aspiration and thrombolysis (FAST) of the clot. Two milligrams of rtPA were administered every 12 h until ICH volume < or =10 cc, or catheter fenestrations were no longer in continuity with the clot. ICH and perihematomal edema volumes were calculated from CT scans. Using random effects linear regression we estimated the rate of hematoma and edema volume resolution as well as their relationship during the first 8 days of lytic therapy.

Results: Fifteen patients were treated, mean age: 60.7 years, median time from ictus to FAST: 1 (range 0-3) day. Using a random effects model that considered volume resolution over the first 8 days following lytic therapy we found that the both percentage hematoma and percentage perihematoma edema resolution per day were quadratic with respect to time. Percentage residual hematoma volume on day K = 97.7% - [24.36%*K] + [1.89%*K (2)]; P < 0.001 for both terms. Percentage residual edema on day K = 97.4% - [13.94%*K] + [1.30%*K (2)]; P < 0.001 for K and P = 0.01 for K (2). Examination of each patient's volume data suggests that there exists a strong direct relationship between perihematoma edema volume and same day hematoma volume.

Conclusions: In this cohort of ICH patients treated using FAST, volumetric analysis of ICH and perihematomal edema seems to suggest that local use of rtPA does not exacerbate brain edema formation. Furthermore, there seems to be a strong association between reduction in ICH volume and reduction in edema volume, as would be expected following the concept of "hemotoxicity" postulated by some investigators.

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References

Thiex R, Kuker W, Muller H, Rohde I, Schroder J, Gilsbach J . The long-term effect of recombinant tissue-plasminogen-activator (rt-PA) on edema formation in a large-animal model of intracerebral hemorrhage. Neurol Res. 2003; 25(3):254-62. DOI: 10.1179/016164103101201463. View

Lapointe M, Haines S . Fibrinolytic therapy for intraventricular hemorrhage in adults. Cochrane Database Syst Rev. 2002; (3):CD003692. PMC: 6991935. DOI: 10.1002/14651858.CD003692. View

Broderick J, Brott T, Duldner J, Tomsick T, Huster G . Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke. 1993; 24(7):987-93. DOI: 10.1161/01.str.24.7.987. View

Montes J, Wong J, Fayad P, Awad I . Stereotactic computed tomographic-guided aspiration and thrombolysis of intracerebral hematoma : protocol and preliminary experience. Stroke. 2001; 31(4):834-40. DOI: 10.1161/01.str.31.4.834. View

Mayer S, Brun N, Begtrup K, Broderick J, Davis S, Diringer M . Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2005; 352(8):777-85. DOI: 10.1056/NEJMoa042991. View

Mohadjer M, Braus D, Myers A, Scheremet R, Krauss J . CT-stereotactic fibrinolysis of spontaneous intracerebral hematomas. Neurosurg Rev. 1992; 15(2):105-10. DOI: 10.1007/BF00313504. View

Naff N, Williams M, Rigamonti D, Keyl P, Hanley D . Blood clot resolution in human cerebrospinal fluid: evidence of first-order kinetics. Neurosurgery. 2001; 49(3):614-9; discussion 619-21. DOI: 10.1097/00006123-200109000-00015. View

Deinsberger W, Lang C, Hornig C, Boeker D . Stereotactic aspiration and fibrinolysis of spontaneous supratentorial intracerebral hematomas versus conservative treatment: a matched-pair study. Zentralbl Neurochir. 2003; 64(4):145-50. DOI: 10.1055/s-2003-44617. View

Tuhrim S, Horowitz D, Sacher M, Godbold J . Volume of ventricular blood is an important determinant of outcome in supratentorial intracerebral hemorrhage. Crit Care Med. 1999; 27(3):617-21. DOI: 10.1097/00003246-199903000-00045. View

10.

Tuhrim S, Dambrosia J, Price T, Mohr J, Wolf P, Hier D . Intracerebral hemorrhage: external validation and extension of a model for prediction of 30-day survival. Ann Neurol. 1991; 29(6):658-63. DOI: 10.1002/ana.410290614. View

11.

Wagner K, Xi G, Hua Y, Zuccarello M, de Courten-Myers G, Broderick J . Ultra-early clot aspiration after lysis with tissue plasminogen activator in a porcine model of intracerebral hemorrhage: edema reduction and blood-brain barrier protection. J Neurosurg. 1999; 90(3):491-8. DOI: 10.3171/jns.1999.90.3.0491. View

12.

Okuda M, Suzuki R, Moriya M, Fujimoto M, Chang C, Fujimoto T . The effect of hematoma removal for reducing the development of brain edema in cases of putaminal hemorrhage. Acta Neurochir Suppl. 2006; 96:74-7. DOI: 10.1007/3-211-30714-1_18. View

13.

Wang Y, Tsirka S, Strickland S, Stieg P, Soriano S, Lipton S . Tissue plasminogen activator (tPA) increases neuronal damage after focal cerebral ischemia in wild-type and tPA-deficient mice. Nat Med. 1998; 4(2):228-31. DOI: 10.1038/nm0298-228. View

14.

Naff N, Carhuapoma J, Williams M, Bhardwaj A, Ulatowski J, Bederson J . Treatment of intraventricular hemorrhage with urokinase : effects on 30-Day survival. Stroke. 2001; 31(4):841-7. DOI: 10.1161/01.str.31.4.841. View

15.

Zuccarello M, Andrioli G, Trincia G, Pardatscher K . Spontaneous intracerebral haematomas. Aspects of treatment. Zentralbl Neurochir. 1983; 44(3):209-13. View

16.

Yepes M, Sandkvist M, Moore E, Bugge T, Strickland D, Lawrence D . Tissue-type plasminogen activator induces opening of the blood-brain barrier via the LDL receptor-related protein. J Clin Invest. 2003; 112(10):1533-40. PMC: 259131. DOI: 10.1172/JCI19212. View

17.

Niizuma H, Otsuki T, Johkura H, Nakazato N, Suzuki J . CT-guided stereotactic aspiration of intracerebral hematoma--result of a hematoma-lysis method using urokinase. Appl Neurophysiol. 1985; 48(1-6):427-30. DOI: 10.1159/000101172. View

18.

Barrett R, Hussain R, Coplin W, Berry S, Keyl P, Hanley D . Frameless stereotactic aspiration and thrombolysis of spontaneous intracerebral hemorrhage. Neurocrit Care. 2005; 3(3):237-45. DOI: 10.1385/NCC:3:3:237. View

19.

FIGUEROA B, Keep R, Betz A, Hoff J . Plasminogen activators potentiate thrombin-induced brain injury. Stroke. 1998; 29(6):1202-7; discussion 1208. DOI: 10.1161/01.str.29.6.1202. View

20.

Mendelow A, Gregson B, Fernandes H, Murray G, Teasdale G, Hope D . Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet. 2005; 365(9457):387-97. DOI: 10.1016/S0140-6736(05)17826-X. View