Can a single basal cistern urokinase bolus help to prevent subarachnoid hemorrhage consequences?

Study design: Retrospective. Background: In the 1980s, aneurysmal subarachnoid clot lysis with urokinase or alteplase (rtPA) was proven to effectively reduce vasospasm and neurological ischemic deficits, improving survival and clinical outcomes. This therapeutic option has been less commonly used since the introduction of endovascular treatment, but renewed interest has sparked in recent years. Aims: To investigate if single bolus cisternal urokinase subarachnoid clot lysis reduces vasospasm, neurological ischemic deficits, mortality, and permanent CSF diversion rates and improves outcomes. Additionally, we want to unveil which subgroup of patients benefit most. Material and methods: Study period January 2007-December 2019. 415 patients with saccular aneurysms and >1-year follow-up analyzed. Six groups created according to the treatment applied: no treatment (42), only external ventricular drain (16), endovascular treatment (155), clipping (53), clipping + 100,000UI urokinase (116), and incidental brain aneurysm (33). Results: The rates and severity of vasospasm, permanent CSF diversion, and mortality in Fisher grades ≥3 subarachnoid hemorrhages were higher with endovascular treatment than with surgical clipping with simultaneous cisternal urokinase administration. The best GOSE results on discharge and 6- and 12-month follow-ups happened in this latter group. The differences were more significant the higher the Fisher grade. We neither saw intraventricular, subarachnoid, subdural, or epidural hemorrhages nor systemic fibrinolysis or infections that could be related to the urokinase administration. Conclusions: Single bolus cisternal 100,000UI urokinase administration during emergency aneurysm clipping reduces vasospasm, mortality, and the need for permanent CSF diversion. It is not associated with a significant increase in intracranial hemorrhages or systemic fibrinolysis.