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MDTs Cannot Always Predict Results With Salvage Surgery Surgical Outcome of Patients Considered to Have " Inoperable " Tumors By Specialized Pediatric Neuro-Oncological Multidisciplinary Teams

Background: Despite modern advances, aneurysmal subarachnoid hemorrhage (SAH) is still associated with high morbidity and mortality rates in part due to vasospasm and hydrocephalus-related complications. Objective: To analyze the impact of administration of intraventricular tissue plasminogen activator (tPA) with or without concurrent lumbar drainage, on the rate of cerebrospinal fluid shunt placement and on the incidence and severity of vasospasm. Participants/Methods: This study compares 41 patients who received intraventricular tPA from June 2007 to October 2008, to 35 controls admitted between 2006 and 2007. Data were collected retrospectively. All patients had suffered from aneurysmal SAH, and had an admission Hunt and Hess grade ≥3. The treatment received by both groups was protocol-based and similar except for tPA administration. In total, 5 mg of tPA were given 12 hours after surgical or endovascular aneurysm occlusion via an antibiotic impregnated ventriculostomy catheter. Results: There were no significant demographic differences between the 2 groups. Aneurysm locations were similar. Patients in the tPA treatment arm had significantly lower Hunt and Hess grades but significantly higher presenting Fisher grades compared to controls. Overall, 74% of the tPA group had a lumbar drain versus none in the control group. The average number of tPA doses administered was 6. A ventricular shunt was needed in 17.5% of cases in the tPA group versus 42.8% in the control group. Similarly, tPA patients had a 15% angioplasty rate versus 40% in the control group, and spent fewer days in severe transcranial doppler-defined spasm. When an intervention was needed, the number of vessels angioplastied was 2.1 in tPA patients versus 3.5 in control patients. The 10 patients who received tPA and did not have a lumbar drain showed reduced angioplasty and shunt rates, suggesting an independent protective effect of tPA. Conclusions: In patients suffering from aneurysmal SAH with Hunt and Hess grades ≥3, intraventricular injection of tPA with or without lumbar drainage reduces the need for angioplasty, as well as the number of vessels requiring treatment if angioplasty is deemed necessary. It also minimizes the duration of severe vasospasm and the need for cerebrospinal fluid shunting within 3 months after the hemorrhage. Reviewer's Comments: Advances in the management and prevention of SAH-related complications have been slow to materialize. This paper revisits the idea that reducing the clot burden in the ventricles may improve outcomes after aneurysmal SAH. The study design is by no means flawless. Still, the results reported here are encouraging. A prospective blinded randomized trial is warranted though before recommendations can be made. (Reviewer-Bernard R. Bendok, MD).