PURPOSE: The authors present a prospective study on 10 patients with stereotactic infusion of tissue plasminogen activator (rtPA) intraparenchimal hemorrhage. METHODS: Between 1999 and 2000, 10 patients with deep seated hematomas in the basal ganglia were selected for stereotactic infusion of rtPA and spontaneous clot drainage. RESULTS: All cases had about 80% reduction of the hematoma volume in the CT scan at the third day. The intracranial pressure was normalized by the third day too. There were no local or systemic complications with the use of this trombolitic. The results were shown by the Glasgow Outcome Scale with six patients in V, three in IV and one in III after 3 months. CONCLUSION: Early treatment and drainage with minimally invasive neurosurgery , can make these patients with deep-seated hematomas recover the consciousness and they can be rehabilitated earlier avoiding secondary complications.OBJETIVO: Estudo prospectivo em 10 pacientes com infusão de trombolítico (rtPA) dentro do hematoma cerebral profundo supratentorial e drenagem estereotáxica. MÉTODO: Entre 1999 e 2000 10 pacientes com hematomas de profundidade foram selecionados para infusão de rtPA e drenagem do coágulo espontânea. RESULTADO: Todos os casos obtiveram 80% de redução do volume do hematoma medidos por TC no terceiro dia. A pressão intracraniana estava normalizada no terceiro dia. Não houve complicações locais ou sistêmicas relacionadas com o uso deste trombolítico. Os resultados comparados foram mostrados pela Escala de Prognóstico de Glasgow com 6 pacientes em GrauV, 3 pacientes em Grau IV e 1 paciente em Grau III após três meses. CONCLUSÃO: Tratamento precoce e drenagem com técnica neurocirúrgica minimamente invasiva pode fazer estes pacientes terem uma recuperação da consciência mais rápida e assim serem reabilitados mais precocemente evitando complicações secundárias.Universidade Estácio de Sá Instituto do Sono Estácio de Sá Centro de Investigação NeurológicaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Alaminos, Armando

Bezerra, Márcio

Bonatelli, Antônio

Falavigna, Asdrubal

Ferraz, Fernando

Freitas, Gabriel

Martinez, Victor

Nasser, José Augusto

Arquivos de Neuro-Psiquiatria

PURPOSE: The authors present a prospective study on 10 patients with stereotactic infusion of tissue plasminogen activator (rtPA) intraparenchimal hemorrhage. METHODS: Between 1999 and 2000, 10 patients with deep seated hematomas in the basal ganglia were selected for stereotactic infusion of rtPA and spontaneous clot drainage. RESULTS: All cases had about 80% reduction of the hematoma volume in the CT scan at the third day. The intracranial pressure was normalized by the third day too. There were no local or systemic complications with the use of this trombolitic. The results were shown by the Glasgow Outcome Scale with six patients in V, three in IV and one in III after 3 months. CONCLUSION: Early treatment and drainage with minimally invasive neurosurgery , can make these patients with deep-seated hematomas recover the consciousness and they can be rehabilitated earlier avoiding secondary complications.OBJETIVO: Estudo prospectivo em 10 pacientes com infusão de trombolítico (rtPA) dentro do hematoma cerebral profundo supratentorial e drenagem estereotáxica. MÉTODO: Entre 1999 e 2000 10 pacientes com hematomas de profundidade foram selecionados para infusão de rtPA e drenagem do coágulo espontânea. RESULTADO: Todos os casos obtiveram 80% de redução do volume do hematoma medidos por TC no terceiro dia. A pressão intracraniana estava normalizada no terceiro dia. Não houve complicações locais ou sistêmicas relacionadas com o uso deste trombolítico. Os resultados comparados foram mostrados pela Escala de Prognóstico de Glasgow com 6 pacientes em GrauV, 3 pacientes em Grau IV e 1 paciente em Grau III após três meses. CONCLUSÃO: Tratamento precoce e drenagem com técnica neurocirúrgica minimamente invasiva pode fazer estes pacientes terem uma recuperação da consciência mais rápida e assim serem reabilitados mais precocemente evitando complicações secundárias

Scientific Electronic Library Online - Brazil

Fibrinólise com infusão de rtPA e drenagem estereotáxica de hematoma intracerebral espontâneo profundo

Nasser, José Augusto [UNIFESP]

Bezerra, Márcio [UNIFESP]

Martinez, Victor [UNIFESP]

Freitas, Gabriel [UNIFESP]

Bonatelli, Antônio [UNIFESP]

Ferraz, Fernando [UNIFESP]

Repositório Institucional UNIFESP

Arq Neuropsiquiatr 2002;60(2-B):362-366STEREOTACTIC FIBRINOLYSIS OF SPONTANEOUSINTRACEREBRAL HEMATOMA USING INFUSION OFRECOMBINANT TISSUE PLASMINOGEN ACTIVATORJosé Augusto Nasser1/2, Asdrubal Falavigna1, Márcio Bezerra1/2, Victor Martinez1/2,Gabriel Freitas1/2, Armando Alaminos1, Antônio Bonatelli3, Fernando Ferraz3ABSTRACT  Purpose: The authors present a prospective study on 10 patients with stereotactic infusion oftissue plasminogen activator (rtPA) intraparenchimal hemorrhage. Methods: Between 1999 and 2000, 10patients with deep seated hematomas in the basal ganglia were selected for stereotactic infusion of rtPA andspontaneous clot drainage. Results: All cases had about 80% reduction of the hematoma volume in the CTscan at the third day. The intracranial pressure was normalized by the third day too. There were no local orsystemic complications with the use of this trombolitic. The results were shown by the Glasgow OutcomeScale with six patients in V, three in IV and one in III after 3 months. Conclusion: Early treatment and drainagewith minimally invasive neurosurgery , can make these patients with deep-seated hematomas recover theconsciousness and they can be rehabilitated earlier avoiding secondary complications.KEY WORDS: hematoma lysis, recombinant tissue plasminogen activator, spontaneous intracerebral hematoma,stereotaxy.Fibrinólise com infusão de rtPA e drenagem estereotáxica de hematoma intracerebral espontâneoprofundoRESUMO  Objetivo: Estudo prospectivo em 10 pacientes com infusão de trombolítico (rtPA) dentro dohematoma cerebral profundo supratentorial e drenagem estereotáxica. Método: Entre 1999 e 2000 10 pacientescom hematomas de profundidade foram selecionados para infusão de rtPA e drenagem do coágulo espontânea.Resultado: Todos os casos obtiveram 80% de redução do volume do hematoma medidos por TC no terceirodia. A pressão intracraniana estava normalizada no terceiro dia. Não houve complicações locais ou sistêmicasrelacionadas com o uso deste trombolítico. Os resultados comparados foram mostrados pela Escala dePrognóstico de Glasgow com 6 pacientes em GrauV, 3 pacientes em Grau IV e 1 paciente em Grau III após trêsmeses. Conclusão: Tratamento precoce e drenagem com técnica neurocirúrgica minimamente invasiva podefazer estes pacientes terem uma recuperação da consciência mais rápida e assim serem reabilitados maisprecocemente evitando complicações secundárias.PALAVRAS-CHAVE: lise do coágulo, hematoma intracerebral, rtPA, estereotaxia.1Departamento de Neurocirurgia da Universidade Estácio de Sá, Centro de Investigação Neurológica e Instituto do Sono Estácio de Sá,Serviço de Neurocirurgia do Hospital Pró-Cardíaco  Rio de Janeiro RJ, Brasil; 2Doutorando pela Escola Paulista de Medicina  UniversidadeFederal de São Paulo SP, Brasil (EPM - UNIFESP); 3Professor Adjunto de Neurocirurgia da EPMUNIFESP.Received 21 September 2001, received in final form 12 December 2001. Accepted 7 January 2002.Dr. José Augusto Nasser - Avenida Ataulfo de Paiva, 1079/1001  22440-031 Rio de Janeiro RJ  Brasil - www.estacio.br/inesFAX: 21 2294 5329. E-mail: nasser@riodejaneiro.netSpontaneous intracerebral hematomas, as knownas (AKA) hypertensive hemorrhages, especially thosedeep-seated, are still highly controversial in termsof conservative or operative therapy1. Neither non-operative therapy nor operative management hasbeen able to reduce the mortality or morbidity, es-pecially since the classical neurosurgical operationfor deep-seated spontaneous intracerebral hemor-rhage is a high-risk procedure and controversial.Surgery is not so controversial if it is in posteriorfossa, because it can promote a fast reduction inbrainstem compression and produces better results.Backlund et al. and Higgins and Nashold were thefirst to report stereotactic evacuation of deep-seatedhemorrhages2,3. They could not complete evacuationof those clots. Doi et al. and Mohadjer et al. reportedtheir experience with urokinase infusion through astereotactically implanted catheter inserted into thehematoma cavity4, 5. Shaller et al. published the firstseries using tissue plasminogen activator (rtPA)through a stereotactic catheter implanted with goodoutcome and few complications6.Arq Neuropsiquiatr 2002;60(2-B) 363This prospective study analyzes the efficacy andsafety of clot lysis with rtPA stereotactically infusedand spontaneous drainage of hypertensive deep in-tracerebral hematoma. Results are compared withcontrol group and the literature is reviewed.METHODPatient populationBetween November 1999 and October 2000 at theemergency room (ER) of Pró-Cardíaco Hospital, 10 patientswith hypertensive spontaneous basal ganglia hematomaswere selected among 24 patients with deep intracerebralhematomas. The mean age was 66.4 years (ranging 61 -74 years) being six males. Six patients were consideredcontrol group. They were not considered surgical candi-dates because even having hypertensive basal ganglia he-matomas they presented one of exclusion items describedbelow.Informed consent for therapy, approved by PróCardíacoHospital ethical committee, was obtained from the pa-tients and/or their relatives.Inclusion and exclusion criteriaPatients were selected based on: a) an impairment ofconsciousness level; b) no signs of herniation (midbrainsymptoms, wide and fixed pupil); c) hematoma volumemore than 30cc; d) less than 48hs of onset; e) no arterio-venous malformation (AVM) in digital angiography sus-pected ; f) no evidence of systemic bleeding disease; g)Glasgow coma scale (GCS) score not less than 5; e) com-plete routine laboratory study negative for blood dyscra-sias, coagulopathies, drug tests, infection and erythrocytesedimentation rate as evidence for vasculitis.Radiological proceduresCT scan was performed in all patients less than 3 hoursof admission. The diameter and thickness of the hematomawas assessed. Patients whom a vascular malformation wassuspected, an angiography was performed before the he-matoma lysis.Operative techniqueThe stereotactic arc was fixed under local anesthesia.A stereotomography was performed. Those images weretransferred to the workstation. At the workstation usingthe MSPS software (A. Alaminos  Micromar - São PauloSP - Brazil) the coordinates for the hematoma center wereacquired. This isocenter was used as our target to insertthe silicone hematoma drainage catheter (Nasser Anti-Block Catheter  Phoenix  Valley Forge  PA- USA) espe-cially designed to this protocol. At the same time the co-ordinates of the lateral ventricle were acquired in order toinsert a silicone ventricular drainage catheter and moni-tor the intracranial pressure (ICP) and had cerebrospinalfluid (CSF) drainage in the presence of intracranial hyper-tension. In the operating room, under local anesthesiathose two catheters were implanted using the ETM-03BStereotactic System (Micromar  São Paulo SP  Brazil),and fixed at the skull. Both catheters were connected in-dividually with an external closed drainage system. Backto the neuroradiological suite, a new CT scan was done tocheck the correct position of those catheters. The patientswere transferred to the Neuro ICU.Hematoma lysis protocolRtPA (Actilyse  Boehringer Ilgelheim - Brazil) infusionwas calculated under Schallers protocol, one milligramof rt-PA equaled a volume of one milliliter6. It is based onthe data from Lippitz and Shaller showing this volume iseffective and low toxicity6. If the maximum diameter ofthe hematoma was 5cm , then 5 mg of rtPA was adminis-tered. The system was closed for 2 hours and then openedthrough a closed drainage system against 0 cm of pres-sure. The authors did not use hematoma evacuators. Thedrainage was kept spontaneous.CT scan was performed after 24 hours to re-evaluatethe hematoma size and calculate the second rtPA dose.The catheters were left in place for an additional 48 hoursto drain the residual blood. The ventricular catheter wasremoved after 24 hours of normal intracranial pressure.Follow upThe results were graded according to the Glaslow Out-come Scale (GOS) ; GOS V, good recovery, GOS IV, moder-ate disability (independent); GOS III, severe disability (de-pendent on others); GOS II, vegetative state; GOS I, dead7.Also a neurologic exam was done to compare the neuro-logical deficits before and after the procedure in long term.RESULTSTable 1 shows 10 patients, admitted at the ER ofPró-Cardíaco Hospital. The maximum diameter ofthose hematomas varied from 4 to 6 cm . All thosepatients had deep seated hematomas, being 5 tha-lamic (3 right and 2 left) and 5 putaminal (3 rightand 2 left). Two patients in whom the history of sys-temic arterial hypertension was not clear before, boththalamic underwent subtraction digital angiographywhich were both normal.At the admission the level of consciousness wasrelated to the hematoma size and location. Five pa-tients were in GCS less than 8. Seven were hemipa-retic and among them, 4 were hypertonic.Six patients presented ventricular clot . Three hadacute hydrocephalus. None needed permanentshunt. The ventricular drainage system was pro-grammed to open and drain only if the intracranialpressure becomes higher than 20mmHg. Otherwiseit worked as a monitoring device. These 3 patientswith acute hydrocephalus the ventricular drainagevolume in each 5 early days exceeded 200ml/day ,364 Arq Neuropsiquiatr 2002;60(2-B)but after 5 days this volume decreased and after 7days the volume and the pressure were normalized .Every patient had a second dose of rt-PA calcu-lated same way the first . None had a third dose. Atthe third day, CT scan showed in all patients reduc-tion of 80% hematoma volume and less perilesionaledema (Fig 1). The hematoma catheter was left inplace for an additional 48 hours to drain the residualblood . The volume drained was ranged from 80 to180 ml of liquefied clot, depending on the hema-tomas volume.The ventricular catheter was removed after 24hours of normal intracranial pressure, usually at thefifth day and with the aspect of the CSF clear.Six patients presented fast improvement in theirconsciousness, in 48 hours (Fig 2). It was less evi-dent to observe it in patients with left thalamic clots.Two patients with left thalamic clot, one right tha-lamic and one left putaminal had less improvementin consciousness level.The mean hospitalizations time was 15 days. Twopatients who stayed longer had left thalamic he-matoma. There were no dead in this series and noside effects related with rtPA .The mean follow up evaluation at 3 months showsthat 6 patients are now in GOS V, 3 patients are inGOS IV and only one is in GOS III. This patient had aleft thalamic hematoma, his GCS score at the ad-mission was 6, and was hemiplegic. He is still hemi-plegic even after 4 months of rehabilitation. Two out3 in GOS 4 had hemiplegia at the admission andnow they improved to grade 3 and 4 in muscleFig 1. Patient 5. Seventy four -year-old man with left hyperten-sive thalamic hematoma and intraventricular clot. A, CT at ad-mission. B, CT on day 3 showing significant reduction of the he-matoma.Fig 2. Patient 9: Seventy two-year-old woman with right tha-lamic hematoma and intraventricular clot. A, CT at admission. B,on day 8 with complete reabsorption of the clot.Arq Neuropsiquiatr 2002;60(2-B) 365strength scale. Those patients are constantly beingfollowed by our rehabilitation service.It is important to mention that all these patientswere admitted in the first 6 hours after ictus. It was ob-served enlargement of the hematoma from the firstCT until the stereo CT in two thalamic hematomas.No side effects were observed with this protocolof rtPA in terms of toxicity or hematoma enlargment.All patients had some improvement regarding GOSor neurologic examinationComparing those surgical patients with controlgroup (non surgical) it was found: a) mean 10 daysless of hospitalization; b) 3 days of recovering ofconsciousness state on surgical against 10 days onnon-surgical; c) morbidity was 25% higher on con-trol group; d) mortality was 0 on surgical group com-pared to 30% on control group caused by intracra-nial hypertension; e) secondary complications were40% more on control group; f) hospitalization costswere two times higher on control group; g) GOSwas predominantly III on control group and IV onsurgical.DISCUSSIONAfter experimental studies and clinical trialsshowed the efficacy and safety of the rtPA instilla-tion in subarachnoid hemorrhage, lysing the clots,some authors based on previous experience withurokinase infusion, started to think about clot lysiswith rtPA8-12 .The prognosis of thalamic hemorrhage has a closecorrelation with hematoma size and ventricular ex-tension of hemorrhage. Chung et al. demonstratedthat the mortality was 81% when thalamic hemor-rhage presented the entire area of the thalamus:global type13. The volume of ventricular blood is animportant determinant of outcome in supratento-rial intracerebral hemorrhage, as shown by Tuhrimet al.14.Reabsorption of hematoma with good neurologi-cal outcome was observed following stereotacticinfusion of rt-PA for clot lysis and drainage in all thosecases except one in the left thalamus, however oncontrol group the results were less impressive.The authors share the idea of Schaller et al., re-garding pure fibrinolytic trial with careful drainageinstead of forceful hematoma aspiration preventingsecondary bleeding6,15. There is a clear benefit usingrtPA over urokinase. There have been some reportsregarding the neurotoxity of urokinase and newbleeding related to urokinase overdose16,17. The riskof using rtPA infusion inside the hematomas isrebleeding . It has been published, but the right se-lection of those patients, with careful investigationof bleeding diseases can be useful to prevent it18.These patients had a good outcome: 60% (GOSV) , 30% (GOS IV) and 10% (GOS III), after 3 monthsfollow-up.The whole procedure was completed in 3 hours.Table 1. Clinical data and octcome of 10 patients with spontaneous basal ganglia hematomas.Patient Sex Age Hematoma size Localization Glasgow coma Glasgow(years) (diameter in cm) scale admission outcome scale*1 M 70 5 L Putamen 9 V2 M 64 5 L Thalamus 6 III3 F 62 4 R Putamen 9 V4 F 68 6 R Putamen 6 V5 M 74 4 L Thalamus 6 IV6 F 68 4 R Thalamus 7 IV7 M 61 5 R Putamen 9 V8 M 62 5 L Putamen 7 V9 F 72 5 R Thalamus 6 V10 M 69 4 R Thalamus 8 IVData Bank from Department of Neurosurgery, Pró-Cardiaco Hospital  Rio de Janeiro  RJ  Brasil.Glasgow outcome scale (GOS): GOS V (good recovery); Gos IV (moderate disability); GOS III (severe disability  depen-dent of others); GOS II (vegetative state); GOS I (dead). *GOS after 3 months.366 Arq Neuropsiquiatr 2002;60(2-B)We know from the literature that during the earlyperiod after the ictus, intracerebral hematomas maycause neurological deterioration as a result of anincreasing mass effect caused by surrounding edema,and this can last up to 4 weeks19,20. The good out-come in these patients could be explained due thefact that admission and diagnosis took about 4hours. Also it seems that in eloquent areas, somedeficits are related with the ischemic caused by themass effect of the hematoma in the surround areas.These results suggest that this procedure is safe,effective on selected patients. Early treatment andevacuation, with stereotactic minimally invasive neu-rosurgery, could make these patients, with deep-seated hematomas, have a recovery of the conscious-ness state and this way they could be rehabilitatedsoon, helping them having less secondary compli-cations.REFERENCES1. Schwarz S, Jauss M, Krieger D, Dorfler A, Albert F, Hacke W.Haematoma evacuation does not improve outcome in spontaneoussupratentorial intracerebral hemorrhage: a case-control study. ActaNeurochir (Wien) 1997;139:897-904.2. Backlund E, van Hoslt M. Controlled subtotal evacuation of intracere-bral hematomas by stereotactic technique. Surg Neurol 1978;9:99-101.3. Higgins AC, Nashold BS. Stereotactic evacuation of large intracerebralhaematomas. Appl Neurophysiol 1980;43:96-103.4. Doi E, Moriwaki M, Komai N, Iwamoto M. Stereotactic evacuation ofintracerebral hematomas. Neurol Med Chir (Tokyo) 1982;22:461-467.5. Mohadjer M, Braus DF, Myers A, Scheremet R, Krauss JK. CT-stereo-tactic fibrinolysis of spontaneous intracerebral hematomas. NeurosurgRev 1992;15:105-110.6. Schaller C, Rohde V, Meyer B, Hassler W. Stereotactic puncture andlysis of spontaneous intracerebral hemorrhage using recombinant tis-sue-plasminogen activator. Neurosurgery 1995;36:328-335.7. Jennett B, Bond M. Assessment of outcome after severe brain damage:a practical scale. Lancet 1975;I:480-484.8. Deinsberger W, Vogel J, Fuchs C, Auer LM, Kuschinsky W, Boker DK.Fibrinolysis and aspiration of experimental intracerebral hematomareduces the volume of ischemic brain in rats. Neurol Res 1999;21:517-523.9. Grabb PA. Traumatic intraventricular hemorrhage treated with intra-ventricular recombinant tissue plasminogen activator: technical casereport. Neurosurgery 1998;43:966-969.10. Kim MH, Kim EY, Song JH, Shin KM. Surgical options of hypertensiveintracerebral hematoma: stereotactic endoscopic removal versus ster-eotactic catheter drainage. J Korean Med Sci 1998;13:533-540.11. Lippitz BE, Mayfrank L, Spetzger U, Warnke JP, Bertalanffy H, GilsbachJM. Lysis of basal ganglia haematoma with recombinant tissue plasmi-nogen activator (rtPA) after stereotactic aspiration: initial results. ActaNeurochir (Wien) 1994;127:157-160.12. Mayfrank L, Lippitz B, Groth M, Bertalanffy H, Gilsbach JM. Effect ofrecombinant tissue plasminogen activator on clot lysis and ventriculardilatation in the treatment of severe intraventricular hemorrhage. ActaNeurochir (Wien) 1993;122:32-38.13. Chung CS, Caplan LR, Han W, Pessin MS, Lee KH, Kim JM. Thalamichemorrhage. Brain 1996;119:1873-1886.14. Thurim S, Horowitz D, Sacher M, Godbold J. Volume of ventricularblood is an important determinant of outcome in supratentorial intrac-erebral hemorrhage. Critical Care Med 1999;27:617-621.15. Amano K, Kawamura H, Tanikawa T, et al.. Surgical treatment of hy-pertensive intracerebral haematoma by CT-guided stereotactic surgery.Acta Neurochir (Wien) 1987;39(Suppl):41-44.16. Masuda T, Dorhmann GJ, Kwaan HC, Erickson RK, Wollman RL. Fi-brinolytic activity in experimental intracerebral hematoma. J Neurosurg1988;68:274-278.17. Yague L, Garcia-March G, Paniagua C, et al. Stereotactic evacuationand local administration in intracerebral haematomas: a comparativestudy. Acta Neurochir (Wien) 1987;39(Suppl):45-48.18. Whitelaw A, Saliba E, Fellman V, Mowinckel MC, Acolet D, MarlowN. Phase I study of intraventricular recombinant tissue plasminogenactivator for treatment of posthaemorrhagic hydrocephalus. Ach DisChild Fetal Neonatal 1996;75:20-26.19. Altumbabic M, Peeling J, Del Biggio MR. Intracerebral hemorrhage inthe rat: effects of hematoma aspiration. Stroke 1998;29:1917-1922.20. Zazulia AR, Diringer MN, Derdeyn CP, Powers WJ. Progression ofmass effect after intracerebral hemorrhage. Stroke 1999;30:1167-1173.

OBJETIVO: Estudo prospectivo em 10 pacientes com infusão de trombolítico (rtPA) dentro do hematoma cerebral profundo supratentorial e drenagem estereotáxica. MÉTODO: Entre 1999 e 2000 10 pacientes com hematomas de profundidade foram selecionados para infusão de rtPA e drenagem do coágulo espontânea. RESULTADO: Todos os casos obtiveram 80% de redução do volume do hematoma medidos por TC no terceiro dia. A pressão intracraniana estava normalizada no terceiro dia. Não houve complicações locais ou sistêmicas relacionadas com o uso deste trombolítico. Os resultados comparados foram mostrados pela Escala de Prognóstico de Glasgow com 6 pacientes em GrauV, 3 pacientes em Grau IV e 1 paciente em Grau III após três meses. CONCLUSÃO: Tratamento precoce e drenagem com técnica neurocirúrgica minimamente invasiva pode fazer estes pacientes terem uma recuperação da consciência mais rápida e assim serem reabilitados mais precocemente evitando complicações secundárias.PURPOSE: The authors present a prospective study on 10 patients with stereotactic infusion of tissue plasminogen activator (rtPA) intraparenchimal hemorrhage. METHODS: Between 1999 and 2000, 10 patients with deep seated hematomas in the basal ganglia were selected for stereotactic infusion of rtPA and spontaneous clot drainage. RESULTS: All cases had about 80% reduction of the hematoma volume in the CT scan at the third day. The intracranial pressure was normalized by the third day too. There were no local or systemic complications with the use of this trombolitic. The results were shown by the Glasgow Outcome Scale with six patients in V, three in IV and one in III after 3 months. CONCLUSION: Early treatment and drainage with minimally invasive neurosurgery , can make these patients with deep-seated hematomas recover the consciousness and they can be rehabilitated earlier avoiding secondary complications.Universidade Estácio de Sá Instituto do Sono Estácio de Sá Centro de Investigação NeurológicaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

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Fibrinólise com infusão de rtPA e drenagem estereotáxica de hematoma intracerebral espontâneo profundo

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