Efficacy of tissue Plasminogen Activator in Patients with Massive Subarachnoid Hemorrhage by Aneurysmal Rupture

Kwon, Sun; Park, Jun Bum; Kim, Hyun Jung; Kwun, Byung Duk

Abstract

OBJECTIVE
There is a close relationship between the amount of hematoma and vasospasm in aneurysmal subarachnoid hemorrhage (SAH). Tissue plasminogen activator (t-PA) has been used as a safe agent to remove these hematoma. This study aims to find a benefit effect of the intracisternal t-PA use in the patients with massive SAH.
METHODS
There were 25 patients who had been treated with intracisternal t- PA to remove the hematoma in the cases with massive SAH during recent 5 years. We enrolled the control group (N=25) which had same Fisher grade, Hunt-Hess grade, and age compared with t-PA treated group. And the prophylactic and therapeutic treatment modalities for vasospasm were the same in both groups except t-PA use. We compared the incidence of clinical vasospasm and delayed cerebral ischemia (DCI), Glasgow Outcome Scale (GOS) score after 3 months, mortality rate, clearance time of basal cisternal hematoma on CT, and the incidence of hydrocephalus and the number of ventriculo-peritoneal (V-P) shunt operation between two groups. Chi square test and independent t-test (SPSS version 12.0, p<0.05) were used in statistical evaluation.
RESULTS
The incidences of clinical vasospasm and DCI had no significant difference between two groups (p=0.765, p=0.157). There were also no significant differences of GOS scores at 3months between two groups (p=0.657). However, the incidences of DCI resulted from clinical vasospasm were 11% (1/9) and 50% (4/8), and so there was 30.8% of risk reduction (95% CI, 0.136~0.695, p=0.015). Mortality rates were 8% (N=2) in t-PA treated group and 16% (N=4) in control group. The causes of death were not related to the vasospasm in t-PA group and were related to the vasospasm in 3 out of 4 in the control group. The mean clearance time of cisternal clot on CT after surgery was 3.24+/-1.56 days in t-PA group and 6.39+/-1.83 days in control group (p<0.001). The incidences of hydrocephalus were not different significantly between two groups (p=0.556) but the rate of V-P shunt operation in t-PA group (25%, 2/8) was lower than that in control group (60%, 6/10) (p=0.138).
CONCLUSION
Intracisternal t-PA use in the patients with thick and massive SAH can lower significantly the incidence of the DCI caused by clinical vasospasm, and may decrease the mortality rate associated with clinical vasospasm, and may prevent V-P shunt operation resulted from post-hemorrhagic hydrocephalus. We assumed that t-PA use was effective especially in the patients with thick and massive SAH, and prospective randomized study was necessary.