Local Fibrinolysis and Possibility of Its Use in Surgical Treatment of Different Intracranial Hemorrhages

V.V. Krylov, S.A. Burov, V.G. Dashyan, A.E. Talypov, I.E. Galankina

(Sklifosovsky Research Institute of Emergency Care, Moscow
Moscow State Medical-Stomatologic University, Moscow)

The study goal was to estimate possibility of using local fibrinolysis in surgical removal of intracranial hemorrhages of different etiology and localization.

Materials and Methods. The study was carried out on 74 cases with intracranial hemorrhages of different etiology. The patients were divided into 3 groups, depending on a hemorrhage cause.

The first group included 21 cases (17 males and 4 females), aged 16-68. All of them had traumatic intracranial hematomas of various localization. Two patients were operated for acute epidural hematomas (25 cm3 and 41 cm3); 12 cases had acute subdural hematomas with a volume, ranging from 30 up to 65 cm3 (a mean volume of 47±2 cm3); intracerebral hematomas with a volume of 28-37 cm3 (a mean volume of 32±2 cm3) were diagnosed in 3 cases; there were 2 epidural hematomas (25 cm3 and 32 cm3) of subtentorial localization. Two patients were operated for multiple traumatic hematomas. One of them had bilateral epidural hematomas (25 cm3 and 38 cm3) and the second bilateral intracerebral hematomas of frontal lobes (13 cm3 and 18 cm3).

The second group was represented by 22 patients with primary massive intraventricular hemorrhages, caused by ruptures of aneurysms and arteriovenous malformations. There were 14 males and 8 females. A mean age was 47.2±2 years.

The third group consisted of 31 cases with hypertensive intracerebral hemorrhages. There age varied from 23 up to 68 years. There were 23 males and 8 females.

The study was based on such methods as a clinical and neurological examination with estimation of consciousness on the basis of Glasgow Coma Scale, CT examination on admission and 12, 24, 48, 72 hours after fibrinolysis, monitoring of intracranial pressure, transcranial Doppler, evaluating morphometric changes of hematomas and perifocal areas of the brain against a background of an effect, conditioned by fibrinolytic drugs.

The operation consisted in making a burr hole in projection of hematoma, its puncture with a silicone catheter and subsequent fibrinolysis and aspiration. Streptokinase and recombinant prourokinase were used as fibrinolytic preparations.

Results. Fibrinolysis made it possible to achieve complete removal of intracranial hematomas in all cases of the first group. Time of hematoma evacuation was as follows: 12 hours after operation 2, 24 hours 10, 48 hours 7 and 72 hours - 2 cases. A state on discharge was satisfactory in 18 out of 21 cases (86%). Gross focal neurological disorders were watched in 2 cases (9.5%); 1 patient died (8.5%). Repeated interventions for recurrent hemorrhages were performed in 2 cases.

Use of streptokinase in patients with intraventricular hemorrhages allowed to improve a state of the ventricular system and to restore liquor circulation by the third day after hemorrhage on the average. According to the values of ventricular coefficients, there was 70% resolution of occlusive hydrocephalus in all patients.

As for the cases of the third group, evacuation of 66-92% of hematoma volume was attained in 74% of them during 24-48 hours. Good restoration during the first 2-4 weeks after operation was watched in 4 cases (13%). Moderate and severe invalidism was observed in 7 (22.5%) and 15 (48%) cases respectively; 5 patients died (16.5%).

Conclusion. Intracranial hemorrhages of traumatic and hypertensive genesis, different localization and volume were removed successfully with the help of little-traumatic local fibrinolysis. Its use was characterized by low postoperative mortality.