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  • Long-term Outcomes after Intraventricular Thrombolysis and Endovascular Therapy for High-Grade Aneurysmal Subarachnoid Hemorrhage

    Final Number:

    John H. Wong MD, MSc; Alim P. Mitha MD, SM; Andreas H Kramer MD

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Chemical thrombolysis with intraventricular tissue plasminogen activator (TPA) after endovascular aneurysm occlusion, may offer benefit related to accelerated clot clearance from the subarachnoid and intraventricular spaces. We examined the long-term results of our local policy of treating patients with high-grade aneurysmal subarachnoid hemorrhage, with intraventricular TPA after endovascular aneurysm occlusion with a view towards safety and feasibility.

    Methods: From 2002-2007, we initiated a prospective institutional protocol of acutely treating selected patients with high-grade SAH (Hunt-Hess grades 3-5) and large volume subarachnoid and intraventricular hemorrhage (Fisher grades 3-4) after aneurysm occlusion, with intraventricular dose(s) of TPA. Long-term follow-up of clinical recovery and radiological surveillance was performed annually or more in a specialty clinic.

    Results: Twenty-two patients (64% female, mean age 55 years) were identified. All expect one had diffuse thick SAH with intraventricular blood, and all required external ventricular drainage. Six patients were initially classified as Hunt-Hess grade 5, 12 patients were grade 4, and 4 were grade 3. All were treated acutely by coil embolization except two with n-acetyl cyanoacrylate. All patients underwent (repeated) dosing of TPA, typically in 4 mg aliquots, via the ventriculostomy catheter. Serial imaging showed evidence of significant new bleeding after treatment in two patients (9%) but the remaining 91% of patients had substantial reduction in amount of intracranial blood. Followup angiography in 16 patients showed three had severe radiologic vasospasm (19%), one moderate (6%), five mild (31%), and seven none (44%). Two moribund patients died due to refractory intracranial hypertension. Long-term clinical follow-up of 17 survivors showed no to slight disability in 9 (53%), moderate disability in 4 (24%), and severe disability in 4 (24%).

    Conclusions: In high-grade aneurysmal SAH, endovascular aneurysm treatment combined with intraventricular thrombolysis is feasible, accelerates clearance of subarachnoid and intracranial blood, and may be associated with favorable long-term outcomes. Further studies are warranted.

    Patient Care: Our protocol may offer a method of accelerating clearance of subarachnoid blood after aneurysm rupture thus reducing its associated sequelae and morbidity.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the rationale for intraventricular thrombolysis after aneurysmal subarachnoid hemorrhage, and 2) Describe its related potential risks and benefits.


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