Prevention of cerebral vasospasm and delayed cerebral ischemia in patients with massive aneurysmal subarachnoid hemorrhage

The study objective is to evaluate the effectiveness and the safety of different cerebrospinal fluid drainage methods and intrathecal fibrinolytic therapy in the prevention of cerebral vasospasm and improving outcomes in patients with massive subarachnoid hemorrhage. Materials and methods. The study was performed on 86 patients with massive aneurismal subarachnoid hemorrhage (Hijdra score >15) who had clipping surgery within 72 h after symptoms onset. We used lumbal drainage in 12 patients (group 1), combined lumbal and cisternal drainage in 24 patients (group 2), lumbal and cisternal drainage with intrathecal fibrinolytic therapy with recombinant staphylokinase in 25 patients (group 3); control group (group 4) included 25 patients with similar clinical and instrumental data. Results. Incidence of unfavorable outcome and symptomatic cerebral vasospasm was 83 and 83 %, respectively (in group 1), 36.8 and 47.4 % (in group 2), 9.1 and 9.1 % (in group 3), 76 and 60 % (in group 4). Conclusion. The proposed intrathecal fibrinolytic therapy with recombinant staphylokinase may be effective and safe to reduce the severity of cerebral vasospasm, improve clinical outcome and lower frequency of normal pressure hydrocephalus after aneurysm rupture.

1. Krylov V.V., Dash’yan V.G., Shatokhin T.A. et al. The timing of open surgical treatment for patients with massive basal subarachnoid hemorrhage (Fisher 3) because of cerebral aneurysms rupture. Neyrokhirurgiya = Russian Journal of Neurosurgery 2015;(3):11–7. (In Russ.)

2. Bretz J.S., Von Dincklage F., Woitzik J. et al. The Hijdra scale has significant prognostic value for the functional outcome of Fisher grade 3 patients with subarachnoid hemorrhage. Clin Neuroradiol 2017;27(3):361–9. DOI: 10.1007/s00062-016-0509-0. PMID: 27113903.

3. Van Norden A.G., van Dijk G.W., van Huizen M.D. et al. Interobserver agreement and predictive value for outcome of two rating scales for the amount of extravasated blood after aneurysmal subarachnoid haemorrhage. J Neurol 2006;253(9):1217–20. DOI: 10.1007/s00415-006-0205-0. PMID: 16998645.

4. Woo P.Y.M., Tse T.P.K., Chan R.S.K. et al. Computed tomography interobserver agreement in the assessment of aneurysmal subarachnoid hemorrhage and predictors for clinical outcome. J Neurointerv Surg 2017;9(11):1118–24. DOI: 10.1136/neurintsurg-2016-012576. PMID: 29030464.

5. Mizukami M., Kawase T., Usami T., Tazawa T. Prevention of vasospasm by early operation with removal of subarachnoid blood. Neurosurgery 1982;10(3):301–7. PMID: 7070631.

6. Ohta H., Ito Z., Yasui N., Suzuki A. Extensive evacuation of subarachnoid clot for prevention of vasospasm – effective or not? Acta Neurochir (Wien) 1982; 63(1–4):111–6. PMID: 7102399.

7. Ito U., Tomita H., Yamazaki S. et al. Enhanced cisternal drainage and cerebral vasospasm in early aneurysm surgery. Acta Neurochir (Wien) 1986;80(1–2):18–23. PMID: 3706009.

8. Inagawa T., Kamiya K., Matsuda Y. Effect of continuous cisternal drainage on cerebral vasospasm. Acta Neurochir (Wien) 1991;112(1–2):28–36. PMID: 1763681.

9. Klimo P. Jr, Kestle J.R., MacDonald J.D., Schmidt R.H. Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage. J Neurosurg 2004;100(2):215–24. DOI: 10.3171/jns.2004.100.2.0215. PMID: 15086227.

10. Park S., Yang N., Seo E. The effectiveness of lumbar cerebrospinal fluid drainage to reduce the cerebral vasospasm after surgical clipping for aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2015;57(3):167–73. DOI: 10.3340/jkns.2015.57.3.167. PMID: 25810855.

11. Kasuya H., Shimizu T., Kagawa M. The effect of continuous drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage: a retrospective analysis of 108 patients. Neurosurgery 1991;28(1):56–9. PMID: 1994282.

12. Collen D. Staphylokinase: a potent, uniquely fibrin-selective thrombolytic agent. Nat Med 1998;4(3):279–84. PMID: 9500599.

13. Verstraete M. Third-generation thrombolytic drugs. Am J Med 2000;109(1):52–8. PMID: 10936478.

14. Kunadian V., Gibson C.M. Trombolytics and myocardial infarction. Cadriovasc Ther 2012;30(2):e81–8. DOI: 10.1111/j.1755-5922.2010.00239.x. PMID: 21070617.

15. Hunt W.E., Hess R.M. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968;28(1):14–20. DOI: 10.3171/

16. jns.1968.28.1.0014. PMID: 5635959.

17. Teasdale G., Murray G., Parker L., Jennett B. Adding up the Glasgow Coma Score. Acta Neurochir Suppl (Wien) 1979;28(1):13–6. PMID: 290137.

18. Fisher C.M., Kistler J.P., Davis J.M. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980;6(1):1–9. PMID: 7354892.

19. Hijdra A., Brouwers P.J., Vermeulen M., van Gijn J. Grading the amount of blood on computed tomograms after subarachnoid hemorrhage. Stroke 1990;21(8):1156–61. PMID: 2389295.

20. Jennett B., Snoek J., Bond M.R., Brooks N. Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. J Neurol Neurosurg Psy 1981;44(4):285–93. PMID: 6453957.

21. Aaslid R., Markwalder T.M., Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg 1982;57(6):769–74. DOI: 10.3171/jns.1982.57.6.0769. PMID: 7143059.

22. Findlay J.M., Weir B.K., Kassell N.F. et al. Intracisternal recombinant tissue plasminogen activator after aneurysmal subarachnoid hemorrhage. J Neurosurg 1991;75(2):181–8. DOI: 10.3171/jns.1991.75.2.0181. PMID: 1906533.

23. Mizoi K., Yoshimoto T., Takahashi A. et al. Prospective study on the prevention of cerebral vasospasm by intrathecal fibrinolytic therapy with tissue-type plasminogen activator. J Neurosurg 1993;78(3):430–7. DOI: 10.3171/jns.1993.78.3.0430. PMID: 8433145.

24. Nakagomi T., Furuya K., Nagashima H. et al. Surgical procedure and results of cisternal washing therapy for the prevention of cerebral vasospasm following SAH. Acta Neurochir Suppl 2011;110(Pt 2): 105–9. DOI: 10.1007/978-3-7091-0356-2_19. PMID: 21125454.

25. Ohman J., Servo A., Heiskanen O. Effect of intrathecalfibrinolytic therapy on clot lysis and vasospasm in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 1991;75(2):197–201. DOI: 10.3171/jns.1991.75.2.0197. PMID: 1906535.

26. Yamamoto T., Esaki T., Nakao Y., Mori K. Efficacy of low-dose tissue-plasminogen activator intracisternal administration for the prevention of cerebral vasospasm after subarachnoid hemorrhage. World Neurosurg 2010;73(6):675–82. DOI: 10.1016/j.wneu.2010.04.002. PMID: 20934155.

27. Zabramski J.M., Spetzler R.F., Lee K.S. et al. Phase I trial of tissue plasminogen activator for the prevention of vasospasm in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 1991;75(2): 189–96. DOI: 10.3171/jns.1991.75.2.0189. PMID: 1906534.

28. Suzuki J., Yoshimoto T., Onuma T. Early operations for ruptured intracranial aneurysms – study of 31 cases operated on within the first four days after ruptured aneurysm. Neurol Med Chir (Tokyo) 1978;18(1 Pt 1):82–9. PMID: 77499.

29. Taneda M. The significance of early operation in the management of ruptured intracranial aneurysms – an analysis of 251 cases hospitalized within 24 hours after subarachnoid haemorrhage. Acta Neurochir (Wien) 1982;63(1–4):201–8. PMID: 7102411.

30. Kwon O.Y., Kim Y.J., Kim Y.J. et al. The utility and benefits of external lumbar CSF drainage after endovascular coiling on aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2008;43(6):281–7. DOI: 10.3340/jkns.2008.43.6.281. PMID: 19096633.

31. Al-Tamimi Y.Z., Bhargava D., Feltbower R.G. et al. Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage: a prospective, randomized, controlled trial (LUMAS). Stroke 2012;43(3):677–82. DOI: 10.1161/STROKEAHA.111.625731. PMID: 22282887.

32. Kawamoto S., Tsutsumi K., Yoshikawa G. et al. Effectiveness of the head-shaking method combined with cisternal irrigation with urokinase in preventing cerebral vasospasm after subarachnoid hemorrhage. J Neurosurg 2004;100(2):236–43. DOI: 10.3171/jns.2004.100.2.0236. PMID: 15086230.

33. Ogura K., Hara M., Tosaki F., Hirai N. Effect of cisternal drainage after early operation for ruptured intracranial aneurysms. Surg Neurol 1988;30(6):441–4. PMID: 3222722.

34. Yamamoto I., Shimoda M., Yamada S. et al. Indications for cisternal drainage in conjunction with early surgery for ruptured aneurysms and timing of its discontinuation. Neurol Med Chir (Tokyo) 1989;29(5):407–13. PMID: 2477741.

35. Yamada K., Yoshimura S., Enomoto Y. et al. Effectiveness of combining continuous cerebrospinal drainage and intermittent intrathecal urokinase injection therapy in preventing symptomatic vasospasm following aneurysmal subarachnoid haemorrhage. Br J Neurosurg 2008;22(5):649–53. DOI: 10.1080/02688690802256373. PMID: 18686067.

36. Miyamachi K., Sugimoto S., Saito H., Mabuchi S. [Combined therapy of ventriculo-cisternal irrigation with external decompression in acute ruptured aneurysm (In Japanese)]. Hokkaido Igaku Zasshi 1984;59(3):281–5. PMID: 6479846.

37. Otawara Y., Ogasawara K., Kubo Y. et al. Effect of continuous cisternal cerebrospinal fluid drainage for patients with thin subarachnoid hemorrhage. Vasc Health Risk Manag 2007;3(4):401–4. PMID: 17969369.

38. Connolly E.S., Rabinstein A.A., Carhuapoma J.R. et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012;43(6):1711–37. DOI: 10.1161/ STR.0b013e3182587839.PMID: 22556195.

39. Steiner T., Juvela S., Unterberg A. et al. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 2013;35(2):93– 112. DOI: 10.1159/ 000346087. PMID: 23406828.

40. Yoshimine T., Hashimoto N., Kawase T. et al. Evidence-based guidelines for the management of aneurysmal subarachnoid hemorrhage. Neurol Med Chir (Tokyo) 2012;52(6):355–429. PMID: 22912991.

41. Kodama N., Sasaki T., Kawakami M. et al. Cisternal irrigation therapy with urokinase and ascorbic acid for prevention of vasospasm after aneurysmal subarachnoid hemorrhage. Outcome in 217 patients. Surg Neurol 2000;53(2):110–7. PMID: 10713187.

42. Prirodov A.V., Titova G.P., Dydykin S.S. et al. The prophylaxis of cerebral angiospasm developing because of subarachnoid hemorrhage in experiments at rats using fibrinolytic drugs. Neyrokhirurgiya = Russian Journal of Neurosurgery 2016;(4):63–72. (In Russ.)

43. Surgery of intracranial aneurysms. Ed. by V.V. Krylov. In 3 vol. Vol. 1. Moscow: T.A. Alekseev Publishing House, 2011. 432 p. (In Russ.)