STEREOTAXIC PUNCTURE AND LYSIS OF SPONTANEOUS INTRACEREBRAL HEMORRHAGE USING RECOMBINANT TISSUE-PLASMINOGEN ACTIVATOR

WE HAVE TESTED a treatment protocol for intracerebral hemorrhage (ICH) , consisting of stereotactic insertion of a catheter into the clot, he matoma lysis by the injection of a fibrinolytic agent, recombinant tis sue-plasminogen activator (rt-PA), and closed system drainage of the l iquefied clot. Fourteen patients underwent computed tomographically gu ided stereotactic hematoma puncture and silicone tube insertion within 72 hours of intracerebral hemorrhage. The majority (nine patients) su ffered from ganglionic ICH, and the size of the hematoma ranged betwee n 3 x 3 x 4 cm and 7 x 7 x 4 cm (mean, 5.2 x 4 x 3.6 cm). All patients had major neurological deficits with or without an impaired level of consciousness, but without signs of transtentorial herniation. The ini tial, then daily, dose (in milligrams) of rt-PA administered via the s ilicone tube equalled the maximal diameter (in centimeters) of the ori ginal and remaining clot as measured initially, then daily, by compute d tomographic scan. The number of rt-PA injections was four in one pat ient, three in eight patients, two in four patients, and one in one pa tient, and the total dose of rt-PA required ranged from 5 to 16 mg (me an, 9.9 mg), After rt-PA injection, the tubing was clamped for 2 hours and then opened to drain spontaneously through a closed system agains t 0 cm of pressure. At follow-up 6.6 months (mean) after treatment (ra nging from 3 to 13 months) and according to the Glasgow outcome score, one patient was Grade V, four were Grade IV, five were Grade III, two were Grade II, and two had died. Computed tomographic scans revealed the ICH to be completely resolved within 5 days after initiation of th e protocol in 13 patients. The patients who gained most from this trea tment were those who had been admitted with an impaired level of consc iousness. They regained consciousness as a result of hematoma lysis an d diminished mass effect, as documented by daily computed tomographic scan. This treatment seemed to be simple, effective, and safe, because no side effects were encountered related to therapy. The difference b etween this treatment and other stereotactic treatment protocols is th at this treatment relies on hematoma lysis and spontaneous drainage ra ther than on forceful, and possibly damaging, mechanical aspiration. H owever, the results are preliminary and the treatment is still experim ental.