The main complication of intravenous application of recombinant tissue plasminogen
activator (rtPA) in acute ischemic stroke is secondary intracerebral hemorrhage (sICH),
which occurs in 1.7–8.8% of patients [1, 2], typically in the first 48 h following
rtPA administration. It is associated with a mortality rate of up to 70%, mainly due
to the mass effect of the hematoma [3].
Accordingly, surgical hematoma evacuation appears to be the logical option for potentially
achieving a good patient outcome; however, there is currently no evidence-based therapy
for sICH after rtPA [4, 5], and many neurosurgeons consider early open surgery dangerous
because of frequent bleeding complications, in particular for evacuation of the deep
ganglionic region because of its eloquent anatomical localization. The rebleeding
risk is further aggravated by reperfusion injury in patients who additionally undergo
mechanical recanalization and in patients with tandem occlusion who require platelet
inhibition after stenting of the proximal internal carotid artery (ICA). Medical treatment
is limited to lowering blood pressure, stabilizing vital signs, and reversal of potential
coagulopathy (administration of prothrombin complex concentrate, fresh frozen plasma,
or aminocaproic acid) to halt hematoma expansion [4]. However, medical treatment to
reverse rtPA-induced coagulopathy is not evidence based and, above all, does not influence
the space-occupying effect of the hematoma that is already present. In summary, there
are no current evidence-based guidelines that address the medical and surgical management
of thrombolysis-associated sICH [4, 5].
A recently published case series described a free-hand bedside catheter technique
for emergency hematoma evacuation in well-accessible lobar hemorrhage following systemic
thrombolysis within 24 h [3]. We now report a consecutive series of six patients who
underwent free-hand bedside catheter evacuation of deep ganglionic hemorrhage into
the infarct core after combined systemic thrombolysis and thrombectomy. In this case
series, patients were treated with the free-hand catheter technique when the following
criteria were fulfilled:
Secondary deep ganglionic hemorrhage (sICH) within 48 h of thrombolysis with rtPA
(dose [in milligrams] = 0.9 times estimated body weight in kilograms) for treatment
of ischemic stroke (with or without mechanical thrombectomy or stenting of the proximal
ICA), core infarct volume ≤ 50 mL
Space-occupying hematoma volume > 40 mL
Reduced level of consciousness due to sICH (somnolence at the least) and deterioration
of the NIHSS by at least four points compared to that at admission
International normalized ratio (INR) < 1.3, partial thromboplastin time < 35 s, platelet
count > 100,000/µL
The study was approved by our local ethics committee (institutional review board registration
number 161/19).
Clot evacuation by open craniotomy within 48 h of systemic thrombolysis is not recommended
by our institutional protocol. However, the establishment of hemorrhage stability
prior to catheter placement is compulsory; hence, all patients received medical treatment.
Systolic blood pressure is lowered to < 140 mm Hg using intravenous medication such
as urapidil, dihydralazine, and/or clonidine, and oxygen is supplied to patients whose
saturation levels are < 95%. Analgosedation and intubation ensue in patients with
a Glasgow Coma Score < 9. Four-factor prothrombin complex concentrates are administered
in patients with an INR > 1.3 (30–50 IU/kg body weight), and platelets are only transfused
when the platelet count is < 100,000/μL (no routine application). The administration
of desmopressin for improvement of platelet dysfunction is not recommended by our
protocol. Furthermore, the application of aminocaproic acid and fresh frozen plasma
is allowed at the discretion of the treating physician.
The locations of the entry point and trajectory of the catheter were determined using
a 3D reconstructed computed tomography (CT) scan. The respective distances to the
targeted catheter tip location both from the midline and the skin level were determined
as previously described [6].
Patients were placed in the supine position for catheter placement. Midline calculation
was performed by measuring the distance from one external auditory meatus to the other.
Transfer of these coordinates to the patient’s head ensued, a scalp area of 6 × 6 cm
was shaved, and the skin was sterilized with ethanol/isopropyl alcohol. Patients received
local anesthesia with 5 mL mepivacaine (infiltration of skin and periosteum) and conscious
sedation using propofol intravenously (median dose 85 mg, range 50–160 mg). No antibiotic
prophylaxis was used.
Twist-drill craniotomy was performed after a 5-mm skin incision. A scaled external
ventricular catheter (10F catheter; Spiegelberg, Hamburg, Germany) was inserted at
an angle, and the depth was calculated via the 3D reconstructed CT scan. In cases
of deep intracerebral hemorrhage occupying the anterior basal ganglia, an anterior
trajectory was generally used, with an entry point at the forehead; a posterior trajectory
was used in cases of deep-seated intracerebral hemorrhage occupying the posterior
basal ganglia or thalamus, with an entry point at the posterior parieto-occipital
area.
Mild aspiration with a 10–20-mL hand-held syringe that was connected to the catheter
was used to facilitate immediate blood drainage; this was achieved by carefully retracting
the piston of the syringe until the first signs of resistance occurred. If no resistance
occurred, a new syringe was attached, and aspiration was carefully repeated until
the first signs of resistance. At that point, the catheter was attached to the skin
and connected to a sterile drainage system. An immediate cranial CT scan was then
performed to verify catheter position and residual hematoma volume. The catheter was
deemed well positioned when the tip fully engaged the blood clot with its fenestrated
segment.
Local thrombolysis was performed as previously described [3], with the following modifications
to the inclusion criteria: Only patients with an infarct core of ≤ 50 mL were included.
In patients in whom the one-step catheter hematoma aspiration did not significantly
reduce the hematoma volume (i.e., to < 50% = surgical target) and did not result in
a significant clinical improvement (i.e., > 4 NIHSS points = clinical target), urokinase
(5,000 IU, 1 mL) was injected > 3 h after catheter placement, and the system was flushed
with 2 mL 0.9% saline. The drain was then clamped for 30 min and reopened for 5.5-h
intervals between bouts of local thrombolysis. The pressure threshold for the collecting
chamber of the drainage system was set at minus 30–40 cm H2O below the foramen of
Monroe to allow for gravitational drainage of the lysed clot. Local thrombolysis (5,000 IU
urokinase) was repeated every 6 h until hematoma volume decreased to < 50% of the
initial volume and the patient showed significant clinical improvement. This treatment
regime was limited to a maximum of 4 days; a cranial CT scan was repeated every 24 h
to evaluate clot size and ensure that the catheter tip had maintained its intrahematomal
position.
Statistical analyses were performed as previously described [3]. Demographic, clinical,
and radiological characteristics of the study patients are shown in Table 1. The median
patient age was 72 years (interquartile range [IQR]: 68–77). The median event-to-thrombolysis
time was 165 min (IQR 142.5–202.5), and the median event-to-thrombectomy time was
290 min (IQR 250–300); all patients had a small infarct core (≤ 12 mL, i.e., below
our predefined threshold of 50 mL maximum core). The median thrombolysis-to-clinical
deterioration time was 10.5 h (range 6–19), and thrombolysis-to-catheter-time was
12.75 h (range 8.5–21). The catheter was inserted 70 min (range 45–90) after sICH
was detected on the CT scan. According to the cranial CT scans, the tip of the catheter
had fully engaged the hematoma in all patients so that no replacement procedure was
necessary.
Table 1
Demographic, clinical, and radiological characteristics of the study patients
Patient 1
Patient 2
Patient 3
Patient 4a
Patient 5
Patient 6b
NIHSS at presentation
18
14
16
15
16
15
Transfer from external stroke unit
Yes
Yes
No
No
No
No
Vessel occlusion
M1-branch of the left MCA
90% stenosis of left ICA
M1-branch of the right MCA
M1-branch of the right MCA
90% stenosis of right ICA
M1-branch of the right MCA
M1-branch of the left MCA
Occlusion of left ICA
M1-branch of the right MCA
Infarct core at admission
Lenticulostriatal (DWI, 10 mL, external clinic)
Lenticulostriatal (CBV, 5 mL, external clinic)
Striatal (DWI, 12 mL)
None (native CT)
Lenticulostriatal (DWI, 9 mL)
None (native CT)
Symptom onset to thrombolysis time (min)
150
135
240
180
210
140
Symptom onset to recanalization time (min)
300
TICI2b
330
TICI2b
300
TICI2b
240
TICI2b
280
TICI3
225
TICI3
ICA stent
acute antithrombotic medication (mg)
Yes
aspirin 300
clopidogrel 300
No
Yes
aspirin 300
clopidogrel 300
No
Yes
aspirin 500
clopidogrel 300
No
Thrombolysis to deterioration time (h)
19
17
10
8
6
11
Thrombolysis to catheter time (h)
21
19.5
12
9.5
8.5
13.5
Deterioration CT to catheter time (min)
55
90
60
45
80
80
NIHSS at deterioration
25
20
24
24
26
23
Ganglionic hematoma volume on CT (mL)
Left
59
Right
47
Right
88
Right
91
Left
96
Right
55
Midline shift (mm)
6
5
8
9
9
3
Aspiration volume (mL)
13
11
14
29
45
19
Postaspiration hematoma volume on CT (mL)
49
38
77
67
57
39
Postaspiration midline shift (mm)
5
4
8
7
6
2.5
NIHSS, post aspiration
22
18
21
22
24
21
Local clot lysis
4 × urokinase 5,000 IU
= 24 h
3 × urokinase 5,000 IU
= 18 h
6 × urokinase 5,000 IU
= 36 h
4 × urokinase 5,000 IU
= 24 h
4 × urokinase 5,000 IU
= 24 h
4 × urokinase 5,000 IU
= 24 h
Hematoma volume after lysis (mL)
13
20
32
12
20
10
Postlysis midline shift (mm)
3
3
5
5.5
4
1
NIHSS at discharge
14 (day 13)
12 (day 14)
13 (day 10)
15 (day 14)
16 (day 11)
14 (day12)
mRS after rehabilitation
3 (week 11)
2 (week 9)
3 (week 8)
4 (week 13)
3 (week 12)
3 (week 10)
CBV, cerebral blood volume, CT, computed tomography, DWI, diffusion weighted imaging,
ICA, internal carotid artery, MCA, middle cerebral artery, mRS, modified Rankin scale,
NIHSS, National Institutes of Health Stroke Scale, TICI, thrombolysis in cerebral
ischemia
aPatient 4 received an external ventricular drainage owing to intraventricular extension
of hemorrhage and hydrocephalus
bPatient 5 received an additional parietal hematoma catheter owing to extension of
ganglionic hemorrhage to the parietal cortex (catheter aspiration only without urokinase,
aspiration volume 20 mL)
Figure 1 shows the imaging results from a patient with sICH at different time points
(on admission, after deterioration, immediately after catheter placement, and after
urokinase application at day 3). The median blood volume after deterioration was 74 mL,
which significantly decreased by 26% to a median of 53 mL (p < 0.05) immediately after
catheter aspiration (Fig. 2). Because the hematoma volume had not decreased to < 50%
(i.e., predefined surgical target) on the cranial CT scan and clinical improvement
following one-step catheterization was not significant (> 4 NIHSS, i.e., predefined
clinical target) in any of the patients, local thrombolysis was initiated in all patients > 3 h
after catheter positioning. Urokinase was administered for a median duration of 24 h,
with a total median dose of 4 × 5,000 IU (range 3–6 × 5,000). The median blood volume
thereby further decreased significantly to 16 mL (IQR 12.25–19.75, p < 0.05) on the
CT scan, 18–36 h after sICH had occurred (24% of initial blood volume). The median
midline shift after sICH was 7 mm and decreased to 5.5 mm immediately after catheter
aspiration. Following local thrombolysis, a further significant reduction to 3.5 mm
(IQR 3–4.75, p < 0.05) was observed. The median NIHSS over time was 16 (IQR 15–16)
on presentation, 24 (IQR 23.25–24.75) at deterioration, 22 (IQR 21–22) post catheterization,
and 14 (IQR 13.25–14.75) at discharge. Following discharge from the rehabilitation
clinic (median 12.5 weeks post ictus [IQR 11.25–13.75]), the modified Rankin scale
score was 3 (range 2–4) (Table 1). None of the patients died during the study period.
Because acute blood samples showed normal values for INR, partial thromboplastin time,
and platelet count, none of the patients required prothrombin complex concentrates,
platelets, or fresh frozen plasma, and no additional coagulopathy reversal (e.g.,
with aminocaproic acid) took place. No procedure-related complications, such as rebleeding
(as defined by any expansion of hematoma volume after catheter placement or local
thrombolysis compared to the previous CT), catheter track bleeding, or infection,
were observed.
Fig. 1
a Magnetic resonance (MR) image of patient 1 at the onset of thrombolysis. b Computed
tomography (CT) image of the same patient following clinical deterioration (NIHSS
of 25, with somnolence, global aphasia, severe right-sided hemiparesis, dysarthria)
19 h after thrombolysis. Note the large hematoma in the area of the infarct core (59 mL),
with diffuse perifocal edema over the left hemisphere (midline shift, 6 mm). c CT
image following bedside catheter placement, in which 13 mL of blood was aspirated.
The cranial CT image showed good positioning of the catheter (black arrow); however,
hematoma size was still substantial (49 mL). The patient’s symptoms had only slightly
improved to an NIHSS score of 22; therefore, urokinase administration was initiated.
d Cranial CT image showing near complete resolution of the hematoma following urokinase
administration (5,000 IU) every 6 h for 24 h
Fig. 2
Evolution of hematoma volume before drainage, after catheter aspiration, and after
local thrombolysis. Data are shown as median, interquartile range, and range
Recently published data on an emergency bedside catheter evacuation technique in patients
with systemic-thrombolysis-associated lobar sICH showed that they are readily accessible
to the free-hand technique [3].
As shown in the presented cases, our technique can also successfully be applied in
patients with deep ganglionic hemorrhage following recanalization therapy with or
without dual antiplatelet therapy. To our knowledge, there are no studies on the use
of alternative minimally invasive surgery techniques, such as endoscopic or CT-guided
stereotactic evacuation, in this patient cohort. However, these alternative evacuation
techniques under vision may be more efficacious in one-step hematoma evacuation. Nevertheless,
they do require a more elaborate setting with anesthesia, analgosedation, and intubation;
an operating room may not be readily available 24/7.
The advantages of our technique are (1) the short delay from event onset to hematoma
evacuation (median 2 h), (2) the short duration of the minimally invasive procedure
itself (15 min) without the need for intubation and an operating room, and (3) the
relatively fast reduction in hematoma size (26% reduction after one-step aspiration,
76% reduction after 18–36 h of thrombolysis), which is associated with significant
mass relief. None of our patients suffered from any catheter-associated side effects.
Furthermore, the first attempt at catheter placement was successful in all patients,
with the tip of the catheter fully engaging the hematoma, thus rendering it suitable
for local clot lysis. This is most likely due to the large hematoma size, the use
of 3D reconstructed CT images for catheter trajectory planning, and the fact that
the catheter placement was performed by experienced neurosurgeons.
However, in contrast to the previous report on lobar sICH, the effect of one-step
catheterization was less pronounced because hematoma size was only reduced by 26%
(versus a 70% reduction in lobar sICH [3]). Nevertheless, all patients showed a slight
improvement of 2–3 NIHSS points after catheter aspiration. However, because neither
of the abovementioned predefined surgical or clinical targets were met, we initiated
additional local thrombolysis in all patients. Local thrombolysis resulted in a further
reduction of hematoma size by 76% within 18–36 h of sICH, compared to the initial
blood volume. This was associated with a further improvement in NIHSS, which was equal
to or better than the NIHSS at admission.
In the MISTIE III trial, a hematoma reduction goal of ≤ 15 mL was targeted and was
reached by 58% of the patients. However, a simple transfer to the cohort in our study
with larger hematoma volumes (median 73.5 mL as compared to 41.8 mL in the MISTIE
III trial) and in which the rebleeding risk is likely to be higher (post rtPA, vulnerable
core infarct, definite reperfusion after thrombectomy in all patients with the risk
of reperfusion injury, dual antiplatelet therapy in three of six patients after ICA
stenting) did not seem rational.
Hence, we postulated that a less strict, more individualized hematoma reduction goal
may be better suited to this cohort. It should take the following factors into account:
(1) the extent of initial hematoma reduction by catheter aspiration, (2) the subsequent
mass-relieving effect, (3) the associated clinical improvement, and (4) the extent
of the infarcted brain tissue.
To achieve this, we adopted a hematoma reduction to < 50% as the surgical target and
improvement of at least 5 NIHSS points as the clinical target to account for the increased
risk of rebleeding in our cohort and allow for a more individualized decision-making.
The major limitations of our case series are the very small sample size, the lack
of a control group, the single-center setting, and the nonavailability of urokinase
in some countries.
In summary, this is the first report of a free-hand bedside catheter technique for
clot evacuation of deep ganglionic sICH, the most feared complication after systemic
thrombolysis and mechanical thrombectomy. This procedure is a relatively fast and
safe rescue therapy that can be considered in the aforementioned patient cohort in
which alternative treatment options are otherwise limited and mortality rate is high.