Basal Ganglia Hemorrhage: Minimally Invasive and Neuro-Navigation Guided Treatment by Injection of Recombinant Tissue-Type Plasminogen Activator (rtPA)

Objective: Since open surgical evacuation of basal ganglia hemorrhage (BGH) as had been proved did not lead to the desired benefit for the patients, we used minimally invasive clot lysis by injection of recombinant tissue-type plasminogen activator (rtPA). Methods: Patients with spontaneous BGH with or without accompanied intraventricular hemorrhage were included in the study. Following diagnosis of BGH by CT scanning, a catheter was inserted through a small burr hole under neuro-navigation assistance into the centre of hemorrhage and three mg rtPA was injected for three consecutive days. CT scans were performed daily to determine the volume of the hemorrhage. The size of hemorrhage was calculated using the ABCs measuring method. The clinical condition of the patients was classified using the Glasgow coma scale (GCS) and Glasgow outcome scale (GOS). Statistical analysis was performed using the Fisher’s exact test and Chi-square with Yates’ correction. The p-values were calculated with two tails and statistical significance was estimated as p-value <0.05. Results: The procedure was performed on 22 patients (11 females and 11 males). The mean age of the patients was 64 years (range: 44–80 years). Among the patients, 7 (31.8%) were considered in a poor clinical condition, 11 (50%) in an intermediate condition and 4 (18.2%) in a good clinical condition. The total mortality was calculated with n=3 (13.64%). The mean volume of hemorrhage before treatment was 35.14 mL (range 11.5 mL – 67.15 mL). After the third injection, a mean volume reduction of 73.05% could be achieved. Considering the accuracy of the neuronavigation dataset, correct placement of the drainage in the assumed center of hemorrhage was confirmed in all cases by CT scanning after the first injection. Re-bleeding occurred in 4 cases (18.2%). Conclusion: Treatment with rt-PA in BGH seems an easy, safe and minimally invasive alternative to open surgical hematoma evacuation and it might be more favorable compared to conservative treatment. In our study, we achieved a mean volume of hemorrhage reduction of 73% after 3 days. Clot lysis alone was not the only predictive factor for a better outcome. Outcome prognosis should take several other co-factors into account such as the age of the patient and the GCS at the time of Admission. Large prospective and randomized trials are still necessary to answer these open questions.