Acta Neurochirurgica

, Volume 160, Issue 6, pp 1159–1165 | Cite as

Effect of irrigation on fibrinolytic rtPA therapy in a clot model of intracerebral haemorrhage: a systematic in vitro study

  • Julia Masomi-Bornwassser
  • Fabio Freguia
  • Hendrik Müller-Werkmeister
  • Oliver Kempski
  • Alf Giese
  • Naureen Keric
Original Article - Vascular



Although fibrinolytic therapy is an upcoming treatment for intracerebral haemorrhage (ICH), standard guidelines are lacking, and some clinical issues persist. Here, we used our recently devised clot model of ICH to systematically analyse effects of irrigation and cerebrospinal fluid (CSF) on fibrinolysis.


In vitro clots of human blood (25 ml) were generated and a catheter irrigation system was applied to deliver fluid/treatment. Clots were weighed before and after treatment and compared to rtPA treatment alone. First various drainage periods (15, 30 and 60 min; n = 3 each) and irrigation rates (0, 15, 90 and 180 ml/h; n = 3–5 each) were tested, followed by rtPA administration (1 mg, 15 min incubation) at each irrigation rate. Potential fibrinolytic effect of CSF was examined by incubation with 5 ml healthy vs. haemorrhagic CSF (n = 3 each). To assess a washout effect treatment with saline (0.9%), rtPA (1 mg) and high-rate irrigation (180 ml/h) were compared with measuring plasminogen level before and after. Furthermore clots were treated with a combination of plasminogen (150% serum concentration) and rtPA (1 mg).


Relative clot end weights after 60 min irrigation system treatments were 66.3 ± 3.8% (0 ml/h), 46.3 ± 9.5% (15 ml/h), 46.5 ± 7.1% (90 ml/h) and 53.3 ± 4.1% (180 ml/h). At a lower irrigation rate (15 ml/h), relative end weights were lowest (49.5 ± 4.6%) after 60 min (15 min: 62 ± 4.3%, p = 0.016; 30 min: 62.90 ± 1.88%, p = 0.012). The combination of rtPA and irrigation produced following relative end weights: 0 ml/h, 35 ± 3.2%; 15 ml/h, 32.1 ± 5.7%; 90 ml/h, 36.7 ± 6.3% and 180 ml/h, 41.9 ± 7.5%. No irrigation (0 ml/h) versus rtPA alone showed a significant difference (p < 0.0001) in higher clot weight reduction by rtPA. Similar rtPA+15 ml/h irrigation achieved a significant higher weight reduction compared to 15 ml/h irrigation alone (p = 0.0124). No differences were evident at 90 and 180 ml/h irrigation rates with and without rtPA. Healthy (55.1 ± 5%) or haemorrhagic (65.2 ± 6.2%) CSF showed no fibrinolytic activity. Plasminogen levels in clots declined dramatically (> 80% initially to < 10%) after 1 mg single rtPA dosing and high-rate (180 ml/h) irrigation. The fibrinolytic benefit of adding plasminogen to rtPA was marginal.


In our in vitro clot model, irrigation combined with rtPA (vs. rtPA alone) conferred no added lytic benefit. Likewise, exposure to haemorrhagic CSF did not increase clot lysis.


rtPA ICH IVH Lysis Tenecteplase Urokinase 



We are grateful to all voluntary blood donors, who made this study possible. We thank Stefan Kindel and Thomas Bauer for the drawing of Fig. 1. We thank Dr. Yasar Luqman Ahmed and Mr. Mohammad Ahsan Sadiq for the proofreading.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The ethics committee of Rhineland-Palatinate approved this study. All blood samples were collected from healthy volunteers who granted informed consent. All CSF samples were obtained through informed patient consent.


  1. 1.
    Morgenstern LB, Hemphill JC III, Anderson C, Becker K, Broderick JP, Connolly ES Jr, Greenberg SM, Huang JN, MacDonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ (2010) American Heart Association stroke council and council on cardiovascular nursing. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 41(9):2108–2129CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D, Turner MB, American Heart Association Statistics Committee, Stroke Statistics Subcommittee (2012) Heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation 125(1):e2–e220CrossRefPubMedGoogle Scholar
  3. 3.
    Abdu E, Hanley DF, Newell DW (2012) Minimally invasive treatment for intracerebral hemorrhage. Neurosurg Focus 32(4):E3CrossRefPubMedGoogle Scholar
  4. 4.
    Kreitzer N, Adeoye O (2013) An update on surgical and medical strategies for intracerebral hemorrhage. Semin Neurol 33:462–467CrossRefPubMedGoogle Scholar
  5. 5.
    Carhuapoma JR, Barrett RJ, Keyl PM, Hanley DF, Johnson RR (2008) Stereotactic aspiration-thrombolysis of intracerebral hemorrhage and its impact on perihematoma brain edema. Neurocrit Care 8:322–329CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Gaberel T, Magheru C, Parienti JJ, Huttner HB, Vivien D, Emery E (2011) Intraventricular fibrinolysis versus external ventricular drainage alone in intraventricular haemorrhage: a meta-analysis. Stroke 42(10):2776–2781CrossRefPubMedGoogle Scholar
  7. 7.
    Hanley DF, Thompsen RE, Muschelli J, Rosenblum M, McBee N, Lane K, Bistran-Hall AJ, Mayo SW, Keyl P, Gandhi D, Morgan TC, Ullman N, Mould WA, Carhuapoma JR, Kase C, Ziai W, Thompson CB, Yenokyan G, Huang E, Broaddus WC, Graham RS, Aldrich EF, Dodd R, Wijman C, Caron JL, Huang J, Camarata P, Mendelow AD, Gregson B, Janis S, Vespa P, Martin N, Awad I, Zuccarello M, Investigators MISTIE (2016) Safety and efficacy of minimally invasive surgery plus alteplase in intracerebral haemorrhage evacuation (MISTIE): a randomised, controlled, open-label, phase 2 trial. Lancet Neurol 15(12):1228–1237CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Lippitz BE, Mayfrank L, Spetzger U, Warnke JP, Bertalanffy H, Gilsbach JM (1994) Lysis of basal ganglia haematoma with recombinant tissue plasminogen activator (rtPA) after stereotactic aspiration: initial results. Acta Neurochir 127(3–4):157–160CrossRefPubMedGoogle Scholar
  9. 9.
    Morgan T, Zuccarello M, Narayan R, Keyl P, Lane K, Hanley D (2008) Preliminary findings of the minimally-invasive surgery plus rtPA for intracerebral hemorrhage evacuation (MISTIE) clinical trial. Acta Neurochir Suppl 105:147–151CrossRefPubMedGoogle Scholar
  10. 10.
    Mould WA, Carhuapoma JR, Muschelli J, Lane K, Morgan TC, McBee NA, Bistran-Hall AJ, Ullman NL, Vespa P, Martin NA, Awad I, Zuccarello M, Hanley DF, Investigators MISTIE (2013) Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke 44(3):627–634CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Schaller C, Rohde V, Meyer B, Hassler W (1995) Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissue-plasminogen activator. Neurosurgery 36(2):328–333CrossRefPubMedGoogle Scholar
  12. 12.
    Staykov D, Bardutzky J, Huttner HB, Schwab S (2011) Intraventricular fibrinolysis for intracerebral hemorrhage with severe ventricular involvement. Neurocrit Care 15(1):194–209CrossRefPubMedGoogle Scholar
  13. 13.
    Thiex R, Rohde V, Rohde I, Mayfrank L, Zeki Z, Thron A, Gilsbach JM, Uhl E (2004) Frame-based and frameless stereotactic hematoma puncture and subsequent fibrinolytic therapy for the treatment of spontaneous intracerebral haemorrhage. J Neurol 251(12):1443–1450CrossRefPubMedGoogle Scholar
  14. 14.
    Naff N, Williams MA, Keyl PM, Tuhrim S, Bullock MR, Mayer SA, Coplin W, Narayan R, Haines S, Cruz-Flores S, Zuccarello M, Brock D, Awad I, Ziai WC, Marmarou A, Rhoney D, McBee N, Lane K, Hanley DF (2011) Low-dose recombinant tissue-type plasminogen activator enhances clot resolution in brain hemorrhage: the intraventricular hemorrhage thrombolysis trial. Stroke 42(11):3009–3016CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Keric N, Masomi-Bornwasser J, Müller-Werkmeister H, Kantelhardt SR, König J, Kempski O, Giese A (2017) Optimization of catheter-based rtPA thrombolysis in a novel in vitro clot model for intracerebral hemorrhage. Biomed Res Int.
  16. 16.
    Ziai WC, Tuhrim S, Lane K, McBee N, Lees K, Dawson J, Butcher K, Vespa P, Wright DW, Keyl PM, Mendelow AD, Wijman C, Lapointe M, John S, Thompson R, Thompson C, Mayo S, Reilly P, Janis S, Awad I, Hanley DF, Investigators CLEARIII (2014) A multicentre, randomized, double-blinded, placebo-controlled phase III study of clot lysis evaluation of accelerated resolution of intraventricular hemorrhage (CLEAR III). Int J Stroke 9(4):536–542CrossRefPubMedGoogle Scholar
  17. 17.
    Hanley DF, Lane K, McBee N, Ziai W, Tuhrim S, Lees KR, Dawson J, Gandhi D, Ullman N, Mould WA, Mayo SW, Mendelow AD, Gregson B, Butcher K, Vespa P, Wright DW, Kase CS, Carhuapoma JR, Keyl PM, Diener-West M, Muschelli J, Betz JF, Thompson CB, Sugar EA, Yenokyan G, Janis S, John S, Harnof S, Lopez GA, Aldrich EF, Harrigan MR, Ansari S, Jallo J, Caron JL, LeDoux D, Adeoye O, Zuccarello M, Adams HP Jr, Rosenblum M, Thompson RE, Awad IA, CLEAR III Investigators (2017) Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet 389(10069):603–611Google Scholar
  18. 18.
    Pieters M, Hekkenberg RT, Barrett-Bergshoeff M, Rijken DC (2004) The effect of 40 kHz ultrasound on tissue plasminogen activator-induced clot lysis in three in vitro models. Ultrasound Med Biol 30:1545–1552CrossRefPubMedGoogle Scholar
  19. 19.
    Ziai WC, Muschelli J, Thompson CB, Keyl PM, Lane K, Shao S, Hanley DF (2012) Factors affecting clot lysis rates in patients with spontaneous intraventricular hemorrhage. Stroke 43(5):1234–1239CrossRefPubMedGoogle Scholar
  20. 20.
    Gilard V, Djoubairou BO, Lepetit A, MEtayer T, Gakuba C, Derey S, Proust F, Emery E, Gaberel T (2017) Small versus large catheters for ventriculostomy in the management of intraventricular hemorrhage. World Neurosurg 97:117–122CrossRefPubMedGoogle Scholar
  21. 21.
    Masomi-Bornwasser J, Winter P, Müller-Werkmeister H, Strand S, König J, Kempski O, Ringel F, Kantelhardt SR, Keric N (2017) Combination of ultrasound and rtPA enhances fibrinolysis in an in vitro clot system. PLoS One 12(11):e0188131. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Barlinn K, Tsivgoulis G, Molina CA, Alexandrov DA, Schafer ME, Alleman J, Alexandrov AV, Investigators TUCSON (2013) Exploratory analysis of estimated acoustic peak rarefaction pressure, recanalization, and outcome in the transcranial ultrasound in clinical sonothrombolysis trial. J Clin Ultrasound 41:354–360CrossRefPubMedGoogle Scholar
  23. 23.
    Praetorius J (2007) Water and solute secretion by the choroid plexus. Pflugers Arch 454(1):1–18CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryUniversity Medical Centre of the Johannes Gutenberg University of MainzMainzGermany
  2. 2.Department of NeuropathologyUniversity- and Knappschaft- Hospital BochumBochumGermany
  3. 3.Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain TherapyAsklepios Klinikum HarburgHamburgGermany
  4. 4.Institute of Neurosurgical PathophysiologyUniversity Medical Centre of the Johannes Gutenberg University of MainzMainzGermany
  5. 5.OrthoCentrum HamburgHamburgGermany

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