gms | German Medical Science

Objective: Treatment of spontaneous intracerebral hemorrhages (ICH) is still a matter of debate: microsurgical evacuation, minimal invasive surgery via image-guided catheter placement and best medical care are commonly used options. Benefit of minimal invasive catheter placement and ICH volume reduction is often counteracted by cytotoxic edema induced by rtPA. Our recent in vitro studies of clot lysis have demonstrated that minimal dosages of recombinant tissue-type plasminogen activator (rtPA) for shorter treatment schedules results in higher clot lysis rates. We therefore adapted our rtPA treatment protocol to accelerated low dose and evaluated the results.

Method: We performed a retrospective observational study in our institution of all patients treated by image-guided catheter placement from January 2013 till November 2014. We compared rtPA administration and dosaging (1 mg per 10 ml ICH diameter once a day for upto 4 days; group A) with the modified protocol (1 mg every 4 to 6 hours in case drainage stops for upto 2 days; group B). Demographic data, ICH location and volume, postoperative catheter position, rtPA-dose and postoperative imaging results were assessed.

Results: We analyzed 169 patients with ICH >30 ml, among those 30 patients obtained a minimal invasive image-guided catheter. In both treatment groups demographic data, volume and location of ICH did not differ significantly. In total there were 8 lobar and 22 deep seated ICH. The mean volume was 55.4 ml (range 30.9 ml - 132 ml). In group A mean total dosage was 7.4 mg, in group B 3.5 mg rtPA. Hematoma lysis could be achieved earlier in group B, however after 3 days good evacuation was obtained in both groups. CT results revealed a tendency of more frequent perifocal edema in group A but no significant difference. Catheter could be removed significantly earlier in group B (mean 72 h in A and 36 h in B).

Conclusions: This study of consecutive ICH patients treated with rtPA shows promising results of a new protocol for ICH lysis: The minimal invasive procedure in patients with ICH >30 ml, rtPA administration in an accelerated and low dose protocol seems to be feasible and effective. We therefore suggest continuation of this protocol in minimal invasive ICH treatment, which offers the perspective of faster relief of mass effect, low cytotoxicity due to shorter rtPA exposure and decresed risk of infection.