Effect of irrigation on fibrinolytic rtPA therapy in a clot model of intracerebral haemorrhage: a systematic in vitro st
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ORIGINAL ARTICLE - VASCULAR
Effect of irrigation on fibrinolytic rtPA therapy in a clot model of intracerebral haemorrhage: a systematic in vitro study Julia Masomi-Bornwassser 1 & Fabio Freguia 1,2 & Hendrik Müller-Werkmeister 1,3 & Oliver Kempski 4 & Alf Giese 1,5 & Naureen Keric 1 Received: 16 November 2017 / Accepted: 9 March 2018 # Springer-Verlag GmbH Austria, part of Springer Nature 2018
Abstract Objective Although fibrinolytic therapy is an upcoming treatment for intracerebral haemorrhage (ICH), standard guidelines are lacking, and some clinical issues persist. Here, we used our recently devised clot model of ICH to systematically analyse effects of irrigation and cerebrospinal fluid (CSF) on fibrinolysis. Methods In vitro clots of human blood (25 ml) were generated and a catheter irrigation system was applied to deliver fluid/ treatment. Clots were weighed before and after treatment and compared to rtPA treatment alone. First various drainage periods (15, 30 and 60 min; n = 3 each) and irrigation rates (0, 15, 90 and 180 ml/h; n = 3–5 each) were tested, followed by rtPA administration (1 mg, 15 min incubation) at each irrigation rate. Potential fibrinolytic effect of CSF was examined by incubation with 5 ml healthy vs. haemorrhagic CSF (n = 3 each). To assess a washout effect treatment with saline (0.9%), rtPA (1 mg) and highrate irrigation (180 ml/h) were compared with measuring plasminogen level before and after. Furthermore clots were treated with a combination of plasminogen (150% serum concentration) and rtPA (1 mg). Results Relative clot end weights after 60 min irrigation system treatments were 66.3 ± 3.8% (0 ml/h), 46.3 ± 9.5% (15 ml/h), 46.5 ± 7.1% (90 ml/h) and 53.3 ± 4.1% (180 ml/h). At a lower irrigation rate (15 ml/h), relative end weights were lowest (49.5 ± 4.6%) after 60 min (15 min: 62 ± 4.3%, p = 0.016; 30 min: 62.90 ± 1.88%, p = 0.012). The combination of rtPA and irrigation produced following relative end weights: 0 ml/h, 35 ± 3.2%; 15 ml/h, 32.1 ± 5.7%; 90 ml/h, 36.7 ± 6.3% and 180 ml/h, 41.9 ± 7.5%. No irrigation (0 ml/h) versus rtPA alone showed a significant difference (p < 0.0001) in higher clot weight reduction by rtPA. Similar rtPA+15 ml/h irrigation achieved a significant higher weight reduction compared to 15 ml/h irrigation alone (p = 0.0124). No differences were evident at 90 and 180 ml/h irrigation rates with and without rtPA. Healthy (55.1 ± 5%) or haemorrhagic (65.2 ± 6.2%) CSF showed no fibrinolytic activity. Plasminogen levels in clots declined dramatically (> 80% initially to < 10%) after 1 mg single rtPA dosing and high-rate (180 ml/h) irrigation. The fibrinolytic benefit of adding plasminogen to rtPA was marginal. Conclusions In our in vitro clot model, irrigation combined with rtPA (vs. rtPA alone) conferred no added lytic benefit. Likewise, exposure to haemorrhagic CSF did not increase clot lysis. Keywords rtPA . ICH . IVH . Lysis . Tenecteplase . Urokinase
This work has been presented as a conference paper in May 2017 at the annual meeting of the Germany Society
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