Cisternal Irrigation Therapy with Urokinase and Ascorbic Acid for Prevention of Vasospasm
Although cerebral vasospasm is one of the most serious complications of aneurysmal subarachnoid hemorrhage (SAH), the optimal treatment of cerebral vasospasm has not yet been established. It has been reported previously that subarachnoid clots are related
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Cisternal Irrigation Therapy with Urokinase and Ascorbic Acid for Prevention of Vasospasm N. Kodama, M. Matsumoto, T. Sasaki, Y. Konno, and T. Sato Department of Neurosurgery, Fukushima Medical School, Fukushima, Japan
Introduction Although cerebral vasospasm is one of the most serious complications of aneurysmal subarachnoid hemorrhage (SAH), the optimal treatment of cerebral vasospasm has not yet been established. It has been reported previously that subarachnoid clots are related to the vasospasm and that vasospasm can be induced by spasmogenic substances released from the clot. Although removal of this thick clot is performed in acute stage surgery for ruptured aneurysms to prevent the occurrence of vasospasm, it is still very difficult to completely remove all of the clot. Over the last 14 years, we have developed a novel method for preventing the occurrence of cerebral vasospasm following acute stage surgery. Cisternal irrigation therapy with urokinase and ascorbic acid was introduced to prevent symptomatic vasospasm following aneurysmal SAH. To dissolve and wash out the subarachnoid clot, cisternal irrigation with urokinase has been used. Ascorbic acid is added to degenerate oxy-hemoglobin, one of the strongest spasmogenic substances, into verdoheme-like products which are non-spasmogenic. The efficacy and safety of this therapy were evaluated. Keywords: Subarachnoid hemorrhage; cerebral vasospasm; cisternal irrigation; urokinase.
Materials and Methods This therapy was performed consecutively in 222 patients (Table I). The degree of SAH of the patients was classified as Fisher CT group 3, and the highest CT number (Hounsfield number) exceeded 60 in the SAH, which suggested a significant risk for symptomatic vasospasm (Fig. I). All patients underwent surgery within 72 hours from the onset ofSAH. After clipping the aneurysm, irrigation tubes
Table I. Summary of Cases ofIrrigation Therapy with Urokinase and Ascorbic Acid No. of cases
222
Age (yrs.) Range Mean
27-87 59.2
Sex (male/female)
93/129
Site of aneurysm AcomA ICA MCA VBA ACA
89 63 55 11 4
Preoperative grade (Hunt & Kosnik) I II III IV V
6 107 73 35
Acorn A anterior communicating artery; ICA internal carotid artery; MCA middle cerebral artery; VBA vertebrobasilar artery.
were placed in the Sylvian fissure (inlet) unilaterally or bilaterally and in the prepontine or chiasmal cistern (outlet) (Fig. 2). In order to prevent postoperative hemorrhage, only lactatedRinger's solution without UK was infused for 12 hours, followed by UK and ascorbic acid irrigation. Lactated-Ringer's solution with UK (120 IV/ml) [l0] and ascorbic acid (4 mg/ml) [7] was infused at a rate of 30 ml/hour/side. The solution for irrigation was adjusted to the same pH (7.2-7.6) and osmotic pressure (280-300 mOsm/Kg) as that of the normal cerebrospinal fluid. A microdrop system was used to control the flow rate, and a milliporefilter was also connected to the infusion tube to prevent infection. The total volume of infused and drainaged fluid was measured every hour to avoid e
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