Intrathecal fibrinolysis with streptokinase in tuberculous meningitis.

The introduction by Cathie (1) of intrathecal streptokinase to prevent and treat blockage of the cerebrospinal pathways led to hopes that the treatment of this serious complication might be greatly improved; and that prevention and removal of the exudate in this disease might shorten the course of treatment and render chemotherapy more effective. These hopes were sustained by later reports (2, 3). On the other hand, Eadie (4, 5) and Lorber (6), both with equal numbers of treated and control cases, were unable to demonstrate benefit from the use of intrathecal streptokinase. The value of streptokinase in the treatment of tuberculous meningitis is therefore debatable. The demonstration by Tillett and Sherry (7) that streptokinase produced an active fibrinolytic system in the pleural cavity, and was of great clinical value in the treatment of clotted hemothorax (8) and empyema (9), suggested re-examination of its value in tuberculous meningitis. The success of these authors appeared in part to be due to the fact that they had shown active fibrinolytic enzyme to be present in the pleural fluids of their treated cases, and had used measurements of fibrinolytic activity to assess dosage and control treatment. A difficulty encountered in the work on tuberculous meningitis has been the proper assessment of dosage to produce free lytic enzyme; in fact no adequate measurements were performed by any of the quoted authors. In view of these uncertainties, clinical trial is not a satisfactory method of approach in deciding the merits or demerits of this treatment, since the immediate clinical assessment of such cases is unreliable, and long term assessment takes at least two years. A quantitative laboratory investigation of the system employed, therefore, seemed warranted in order to eliminate unfruitful methods of therapy. It has been shown (10, 11 ) that streptokinase has