Intracisternal rt-PA during early surgery for aneurysmal subarachnoid hemorrhage: an Italian report

A patient undergoing surgery within 24 hours of aneurysm rupture was administered recombinant tissue plasminogen activator (rt-PA) directly into the basal subarachnoid cisterns after aneurysm clipping. Preoperatively, the patient had diffuse thick subarachnoid blood clots on CT. The rt-PA was given as a single injection of 10 mg. Postoperatively the patient was evaluated by serial CT scans and daily transcranial Doppler (TCD) examinations. An almost complete clot clearance was demonstrated on CT scans carried out on day 2 and day 4 after surgery. TCD studies failed to show any acceleration of blood flow velocity indicative of vasospasm. The postoperative curse was uneventful, without any clinical indication of delayed ischemia and no evidence of progressive hydrocephalus. Considering the data of the literature, as well as our initial experience, it appears that intracisternal thrombolysis with rt-PA can be achieved with relative safety and is effective for large-volume subarachnoid blood collections removal and vasospasm prevention. Results from open trials recently published suggest that a substantial advance in the management of an important subgroup of patients with aneurysmal subarachnoid hemorrhage (SAH) may be in the offing. However, randomized, placebo-controlled trials are still needed to confirm that there is a well-definite clinical benefit from the use of rt-PA. These considerations now call for a nation-wide multicentric italian trial which should be also addressed to evaluate other dose regimens and modalities of application.