Effect of irrigation on fibrinolytic rtPA therapy in a clot model of intracerebral haemorrhage: a systematic in vitro study

Cisternal and intraventricular irrigation in subarachnoid and intraventricular haemorrhage

BACKGROUND

Subarachnoid haemorrhage (SAH) and intraventricular haemorrhage (IVH) are associated with poor patient outcomes. Intraventricular fibrinolysis is effective in clearing IVH and improving patient survival and neurological outcome. By similar rationale, cisternal irrigation has been proposed as a potential method to accelerate haematoma clearance in SAH. We aimed to provide a comprehensive review and meta-analysis evaluating the effect of intraventricular and cisternal irrigation on clinical outcomes in patients with SAH and IVH.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed preparing this systematic review and study selection was performed by multiple investigators. We extracted ORs from the individual studies and aggregated these using a random effects model. The quality of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluations assessment and ROBINS-I or RoB-2.

RESULTS

24 articles were included. In SAH, we found that cisternal irrigation with fibrinolytic agents was associated with reduced mortality (OR: 0.68, 95% CI 0.46 to 1.00), higher probability of favourable functional outcome (OR: 1.80, 95% CI 1.30 to 2.51), and reduced risks of DCI (OR: 0.28, 95% CI 0.18 to 0.42) and cerebral vasospasm (OR: 0.28, 95% CI 0.18 to 0.42), compared with conventional therapy. Cisternal irrigation with vasodilatory agents was associated with lower mortality (OR: 0.32, 95% CI 0.13 to 0.79) and reduced risk of cerebral vasospasm (OR: 0.37, 95% CI 0.17 to 0.79). The evidence for irrigation therapy of IVH was sparse and insufficient to show any significant effect.

CONCLUSION

In this study, we found that cisternal irrigation could improve the prognosis in patients with SAH compared with conventional therapy. There is no evidence to support cisternal irrigation treatment of IVH.

Investigation of Neuroprotective Efficacy of Dexpanthenol in an Experimental Head Injury Model

OBJECTIVE

Dexpanthenol (DXP), which has known neuroprotective effects, has been shown to be beneficial in various experimental models and ischaemic diseases. The aim of this study was to investigate the possible neuroprotective effects of DXP in a traumatic brain injury (TBI) model.

METHODS

Thirty-six Wistar-Albino female rats, approximately 6 months old, weighing 220-285 g were used. All rats were subjected to closed head trauma by dropping a weight of 350 g on the parietal region from a height of 50 cm at an angle of 180 degrees in the prepared head trauma model setup. The rats were divided into four groups as control (group 1), trauma (group 2), trauma + DXP (group 3), and DXP (group 4). In group 3, DXP was administered intraperitoneally at a dose of 500 mg/kg for six times at 30 minutes, 6, 12, 24, 36, and 48 hours. In group 4, DXP was administered intraperitoneally simultaneously with group 3 without causing head trauma. Blood samples were taken from all rats 72 hours later for biochemical examination. After blood samples were taken, rats were decapitated under general anaesthesia. Cerebral tissue samples were taken from decapitated rats for immunohistochemical and histopathological examination.

RESULTS

Cytokine markers were found to be increased in posttraumatic brain tissue. Malondialdehyde and glutathione reductase levels were lower in group 3 compared to group 2. In addition, superoxide dismutase, glutathione peroxidase and catalase levels were significantly higher in group 3 compared to group 2. In histological evaluation, congestion in the piamater layer, cell infiltration, vascular congestion, hemorrhage and neuronal degeneration were significantly decreased in group 3 compared to group 2. DXP seems to be beneficial in neurological recovery in terms of histological and oxidative changes after head trauma in rats.

CONCLUSION

DXP should be further evaluated for its possible therapeutic effect in TBI.

Systematic Analysis of Combined Thrombolysis Using Ultrasound and Different Fibrinolytic Drugs in an in Vitro Clot Model of Intracerebral Hemorrhage

Adequate removal of blood clots by minimally invasive surgery seems to correlate with a better clinical outcome in patients with intracerebral hemorrhages (ICHs). Moreover, neurotoxic effects of recombinant tissue plasminogen activator have been reported. The aim of this study was to improve fibrinolysis using an intra-clot ultrasound application with tenecteplase and urokinase in our established ICH clot model. One hundred thirty clots were produced from 25 or 50 mL of human blood, incubated for different periods and equipped with drainage, through which an ultrasound catheter was placed in 65 treatment clots for 1 h, randomly allocated into three groups: administration of ultrasound, administration of 60 IU of tenecteplase or administration of 30,000 IU urokinase. Relative end weights were compared. This study found a significant increase in thrombolysis caused by a combination of ultrasound and fibrinolytic drugs, whereas ultrasound and tenecteplase are significantly more effective in the treatment of larger and aged clots.

Intrahematomal catheter placement with connection to the ventricular system allows more effective thrombolysis of combined intracerebral and intraventricular hematomas

Intracerebral hematomas (ICH) with intraventricular hemorrhage (IVH) are associated with high morbidity. Catheter-based thrombolysis with recombinant tissue plasminogen activator (rtPA) allows a faster hematoma resolution compared to conservative treatment. However, simultaneous thrombolysis of ICH and IVH is not achievable because the ependyma hinders ICH-lysis if rtPA is given into the ventricles and inversely. We evaluated if the thrombolysis efficacy is enhanced by placing an intrahematomal catheter reaching the ventricle. Patients with ICH plus IVH treated with catheter-based thrombolysis were retrospectively analyzed. Group 1 included patients with an intrahematomal catheter reaching the ventricles and group 2 patients with a catheter placed exclusively in the ICH. The relative hematoma volume reduction (RVR) of ICH and IVH within 3 days was calculated. Furthermore, the patients' outcome, the hydrocephalus incidence, and the infection rate were evaluated. A total of 74 patients were analyzed, of whom 49% had a catheter reaching the ventricle. The mean ICH-RVR (68% vs. 58%, p = 0.0001) and IVH-RVR were significantly higher in group 1 compared to group 2. In group 1, infections occurred more often compared to group 2 (31% vs. 6%, p = 0.005). There was no difference in outcome and in hydrocephalus incidence between both groups. The catheter reaching the ventricles allows simultaneous and more effective thrombolysis of ICH and IVH. We assume that the fibrinolytic property of cerebrospinal fluid itself and a washout effect contribute to these findings. In patients with ICH plus IVH, catheter positioning through the hematoma into the ventricle, and subsequent fibrinolytic therapy should be considered.