Microcatheter Intrathecal Urokinase Infusion Into Cisterna Magna for Prevention of Cerebral Vasospasm

BACKGROUND AND PURPOSE: The feasibility of preventing vasospasm by intrathecal anterograde infusion of urokinase (UK) into the cisterna magna was studied in patients with recently ruptured aneurysms who had just undergone the placement of a Guglielmi detachable coil (GDC). METHODS: Immediately after complete embolization with the use of GDC-10 coils, 15 patients with Hunt and Hess neurological grades III and IV received 60 000 IU of UK in normal saline through a microcatheter advanced into the cisterna magna. UK infusion was repeated once or twice over a period of 2 to 3 days according to a decision based on CT evidence of a subarachnoid clot remaining in the cisterns. Before administering the last UK infusion, we obtained CT confirmation of almost complete clearance of clots in the basal cisterns. RESULTS: In all 15 patients, the microcatheter was advanced easily into the cisterna magna by use of the over-the-wire microcatheter technique. In 8 patients who received thrombolytic therapy within 24 hours of the ictus, there was almost complete clearance of the clot in the basal cisterns within 2 days of suffering the insult. When UK was injected at 24 to 48 hours after the insult, 7 patients manifested CT evidence of clearance at the latest 4 days after suffering the insult. In all 15 patients, CT scans obtained within 24 hours of the final UK administration showed complete resolution of clots in the basal cistern and almost complete resolution of clots in the basal interhemispheric fissure and bilateral proximal sylvian fissures. Although one patient developed a transient neurological deficit, no patients manifested permanent delayed neurological deficits as a result of vasospasm. Outcome assessment according to the Glasgow Outcome Scale, no less than 3 months after GDC placement, revealed good recovery in all patients, and none developed hydrocephalus requiring a shunt procedure. CONCLUSIONS: In patients with recently ruptured aneurysms, GDC placement followed by immediate intrathecal administration of UK from the cisterna magna may be a safe and reasonable means of preventing vasospasms and may result in improved treatment outcomes.