Microcatheter intrathecal urokinase infusion into cisterna magna for prevention of cerebral vasospasm - Preliminary report

Background and Purpose-The feasibility of preventing vasospasm by intrathec al anterograde infusion of urokinase (UK) into the cisterna magna was studi ed in patients with recently ruptured aneurysms who had just undergone the placement of a Guglielmi detachable coil (GDC). Methods-Immediately after complete embolization with the use of GDC-10 coil s, 15 patients with Hunt and Hess neurological grades III and IV received 6 0 000 IU of UK in normal saline through a microcatheter advanced into the c isterna magna. UK infusion was repeated once or twice over a period of 2 to 3 days according to a decision based on CT evidence of a subarachnoid clot remaining in the cisterns. Before administering the last UK infusion, we o btained CT confirmation of almost complete clearance of clots in the basal cisterns. Results-In all 15 patients, the microcatheter was advanced easily into the cisterna magna by use of the over-the-wire microcatheter technique. In 8 pa tients who received thrombolytic therapy within 24 hours of the ictus, ther e was almost complete clearance of the clot in the basal cisterns within 2 days of suffering the insult. When UK was injected at 24 to 48 hours after the insult, 7 patients manifested CT evidence of clearance at the latest 4 days after suffering the insult. In all 15 patients, CT scans obtained with in 24 hours of the final UK administration showed complete resolution of cl ots in the basal cistern and almost complete resolution of clots in the bas al interhemispheric fissure and bilateral proximal sylvian fissures. Althou gh one patient developed a transient neurological deficit, no patients mani fested permanent delayed neurological deficits as a result of vasospasm. Ou tcome assessment according to the Glasgow Outcome Scale, no less than 3 mon ths after GDC placement, revealed good recovery in all patients, and none d eveloped hydrocephalus requiring a shunt procedure. Conclusions-In patients with recently ruptured aneurysms, GDC placement fol lowed by immediate intrathecal administration of UK from the cisterna magna may be a safe and reasonable means of preventing vasospasms and may result in improved treatment outcomes.