Cerebral vasospasm would be one of the most hazardous problems in acute surgery of ruptured aneurysms at present. If only the ultra-early stage operation could completely remove the subarachnoid clots, which are considered to be the main cause of vasospasm, there would be no possibility of vasospasm. Total removal of the clots, however, is technically impossible so far. We attempted not only to dissolve and eliminate the blood clot but also to change the spasmogenic substance into something that has no harm.
We have already reported our experimental studies on vasospasm at the Conference of Surgical Treatment of Stroke in 1985. Its summary was as follows: 1) 120 IU/ml urokinase (UK) was most effective in dissolving clots. 2) Oxyhemoglobin (oxyHb), recognized as one of the spasmogenic substances derived from blood, was changed to the unknown resolved products by ascorbic acid (AsA) in vitro. This change was clarified on absorption curve. 3) These products from oxyHb did not induce vasospasm in acute phase experiment of cats. According to these experimental studies, we have clinically performed the cisternal irrigation therapy with UK and AsA following ultra-early surgery for ruptured aneurysms.
Thirteen cases were chosen among the patients of ruptured aneurysms who have come to our clinic since May 1984. These patients were all in Group III according to Fisher's classification in CT scan and their CT number was over 60, which suggested great possibility of vasospasm. The ages ranged from 36 to 74. According to Hunt & Kosnik, 7 were in Grade II, 5 in Grade III, and 1 in Grade IV. Acom anerysms were 5, MC AN 4, IC AN 3 and AC AN 1. Two or three tubes were inserted to both or either Sylvian fissure and chiasmal cistern depending on the site of subarachnoid clots, and the irrigation with lactated Ringer's solusion was performed at the speed of 20-40 ml/hr. The duration of this irrigation therapy was between 6 to 12 days (mean 8.8 days). UK was administrated 12 hours after the operation and its concentration was 120 IU/ml. AsA(2-4mg/ml) was added from 4 days after onset in 8 cases. CT scan was repeated during irrigation to observe the changes of subarachnoid clots. The outflow of drainage was taken every day and measured in RBC, Hb, FDP and absorption curve.
In 12 cases out of 13, no symptomatic vasospasm was found. One patient developed a slight hemiparesis immediately after stopping the irrigation, but was discharged with no deficit and returned to the normal life. During irrigation, cell proliferation in cerebro-spinal fluid was found in some cases, but did not lead to infection nor any severe complication. The number of the cases is not still enough to prove the effect of our therapy. Cisternal irrigation therapy with UK and AsA, however, might be considered one of the effective methods to prevent vasospasm following ultra-early surgery for the ruptured aneurysms.
