Stereotactic Treatment of Intracerebral Hematoma by Means of a Plasminogen Activator

Abstract

Background and Purpose-Treatment of intracerebral hematoma (ICH) is controversial. An advantage of neurosurgical intervention over conservative treatment of ICH has not been established. Recent reports suggest a favorable effect of stereotactic blood clot removal after liquefaction by means of a plasminogen activator. The SICHPA trial was aimed at investigating the efficacy of this treatment. Methods-A stereotactically placed catheter was used to instill urokinase to liquefy and drain the ICH in 6-hour intervals over 48 hours. From 1996 to 1999, 13 centers entered 71 patients into the study. Patients were randomized into a surgical group (nϭ36) and a nonsurgical group (nϭ35). Admission criteria were the following: age Ͼ45 years, spontaneous supratentorial ICH, Glasgow Eye Motor score ranging from 2 to 10, ICH volume Ͼ10 cm 3 , and treatment within 72 hours. The primary end point was death at 6 months. As secondary end points, ICH volume reduction and overall outcome measured by the modified Rankin scale were chosen. The trial was prematurely stopped as a result of slow patient accrual. Results-Seventy patients were analyzed. Overall mortality at day 180 after stroke was 57%; this included 20 of 36 patients (56%) in the surgical group and 20 of 34 patients (59%) in the nonsurgical group. A significant ICH volume reduction was achieved by the intervention (10% to 20%, PϽ0.05). Logistic regression analysis indicated the possibility of efficacy for surgical treatment (odds ratio, 0.23; 95% confidence interval, 0.05 to 1.20; Pϭ0.08). The odds ratio of mortality combined with modified Rankin scale score 5 at 180 days was also not statistically significant (odds ratio, 0.52; 95% confidence interval, 1.2 to 2.3; Pϭ0.38). Conclusions-Stereotactic aspiration can be performed safely and in a relatively uniform manner; it leads to a modest reduction of 18 mL of hematoma reduction over 7 days when compared with control, which has a 7-mL reduction, and therefore may improve prognosis.

Spontaneous intracerebral hemorrhage: a review

“…To date, there are nine prospective randomized controlled studies in which surgical and medical management of SICH has been compared. 6,9,27,61,84,89,90,120,138 Overall, these studies fail to demonstrate a superiority of either medical or surgical management. The results are also limited by considerable methodological differences among the trials.…”

“…Teernstra and colleagues 120 recently reported results from a multicenter randomized controlled trial of stereotactic drainage involving plasminogen activator compared with medical therapy. They randomized 36 patients to surgery and 35 to medical therapy, and found no statistically significant difference in mortality and morbidity rates at 6 months.…”

A Rat Model of Intracerebral Hemorrhage Permitting Hematoma Aspiration plus Intralesional Injection

“…The European Stroke initiative guidelines recommend stereotactic minimally invasive methods to remove a deep hematoma within 12 h of iCH onset [22]. a trial of stereotactic treatment of intracerebral hematoma by means of a plasminogen activator reported a significant reduction in the hematoma volume by 10-20% via ste-reotactic aspiration [24]. nevertheless, there was no difference in survival at 180 days.…”

Neuroendoscope-assisted evacuation of large intracerebral hematomas: introduction of a new, minimally invasive technique

“…Various surgical approaches have been described to evacuate large, hypertension-based ICHs, including craniotomy and transcortical, 10,13 transsylvian, 6 and transcallosal 7 approaches. In addition, stereotactic aspiration with or without the use of fibrinolytic agents 8,11,17 has also been described. Finally, many surgeons have used endoscopic instrumentation to evacuate large ICHs.…”