Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissue-plasminogen activator

WE HAVE TESTED a treatment protocol for intracerebral hemorrhage (ICH), consisting of stereotactic insertion of a catheter into the clot, hematoma lysis by the injection of a fibrinolytic agent, recombinant tissue-plasminogen activator (rt-PA), and closed system drainage of the liquefied clot. Fourteen patients underwent computed tomographically guided stereotactic hematoma puncture and silicone tube insertion within 72 hours of intracerebral hemorrhage. The majority (nine patients) suffered from ganglionic ICH, and the size of the hematoma ranged between 3 × 3 × 4 cm and 7 × 7 × 4 cm (mean, 5.2 × 4 × 3.6 cm). All patients had major neurological deficits with or without an impaired level of consciousness, but without signs of transtentorial herniation. The initial, then daily, dose (in milligrams) of rt-PA administered via the silicone tube equalled the maximal diameter (in centimeters) of the original and remaining clot as measured initially, then daily, by computed tomographic scan. The number of rt-PA injections was four in one patient, three in eight patients, two in four patients, and one in one patient, and the total dose of rt-PA required ranged from 5 to 16 mg (mean, 9.9 mg). After rt-PA injection, the tubing was clamped for 2 hours and then opened to drain spontaneously through a closed system against 0 cm of pressure. At follow-up 6.6 months (mean) after treatment (ranging from 3 to 13 months) and according to the Glasgow outcome score, one patient was Grade V, four were Grade IV, five were Grade III, two were Grade II, and two had died. Computed tomographic scans revealed the ICH to be completely resolved within 5 days after initiation of the protocol in 13 patients. The patients who gained most from this treatment were those who had been admitted with an impaired level of consciousness. They regained consciousness as a result of hematoma lysis and diminished mass effect, as documented by daily computed tomographic scan. This treatment seemed to be simple, effective, and safe, because no side effects were encountered related to therapy. The difference between this treatment and other stereotactic treatment protocols is that this treatment relies on hematoma lysis and spontaneous drainage rather than on forceful, and possibly damaging, mechanical aspiration. However, the results are preliminary and the treatment is still experimental.