Open Access
CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2025; 44(03): e195-e203
DOI: 10.1055/s-0045-1809961
Original Article

Unveiling the Impact of Intrathecal Fibrinolysis on Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis of Randomized Controlled Trials

Desvendando o impacto da fibrinólise intratecal na hemorragia subaracnoide aneurismática: Uma meta-análise de ensaios clínicos randomizados

Authors

  • John Nolan

    1   Department of Neurosurgery, Undata General Hospital, Palu, Indonesia
  • Audrey Rachel Wijaya

    1   Department of Neurosurgery, Undata General Hospital, Palu, Indonesia
  • Theodorus Kevin Putra Johansyah

    2   Department of Neurosurgery, Udayana University, Bali, Indonesia
  • Gede Aditya Ersa Krisnawan

    2   Department of Neurosurgery, Udayana University, Bali, Indonesia

Funding The author(s) received no financial support for the research.
Preview

Abstract

Objective

Aneurysmal subarachnoid hemorrhage (aSAH) poses a significant challenge in neurological emergencies, demanding effective therapeutic interventions to improve patient outcomes. Intrathecal fibrinolysis has emerged as a potential intervention to promote the resolution of blood clots within the subarachnoid space. within the subarachnoid space.

Methods

Extensive literature searches identified relevant RCTs exploring intrathecal fibrinolysis for aSAH management. Data extraction included study characteristics, the quality assessment of the study, and primary outcomes: delayed ischemic neurological deficit (delayed ischemic neurological deficit (DIND)) occurrence and poor neurological recovery (defined by GOS 1–3 or mRS 3–6). Along with the complications and drug preferences.

Results

9 RCTs were included in this meta-analysis. The majority of the RCTs demonstrate the promising effect of intrathecal fibrinolysis. Intracisternal fibrinolysis was found to significantly diminish the incidence of delayed ischemic neurological deficit (DIND) (RR, 0.54; 95% CI, 0.32–0.91) and poor neurological recovery (defined by GOS 1–3 or mRS 3–6) events (RR, 0.65; 95% CI, 0.47–0.90). The significant impact in delayed ischemic neurological deficit (DIND) events also showed in the subgroup analysis along with urokinase administration (RR, 0.31; 95% CI, 0.16–0.62). While intraventricular fibrinolysis did not achieve statistical significance for the primary outcomes, overall findings suggested a beneficial effect considering the choice of drugs administered.

Conclusion

This comprehensive meta-analysis highlights the potential benefits of intrathecal fibrinolysis in reducing delayed ischemic neurological deficit (DIND) occurrence and improving neurological recovery in aSAH patients. The promising results with intracisternal fibrinolysis and urokinase administration warrant further consideration in treatment protocols. Our findings contribute valuable insights, guiding evidence-based clinical decision-making and promoting advancements in aSAH management.

Resumo

Objetivo

A hemorragia subaracnoide aneurismática (aSAH) representa um grande desafio nas emergências neurológicas, exigindo intervenções terapêuticas eficazes para melhorar os desfechos dos pacientes. A fibrinólise intratecal surge como uma estratégia para promover a resolução de coágulos sanguíneos no espaço subaracnoide.

Métodos

Pesquisas extensivas na literatura identificaram ECRs (Ensaios Clínicos Randomizados) relevantes que exploram a fibrinólise intratecal no manejo da aSAH. A extração de dados incluiu as características dos estudos, avaliação da qualidade e os desfechos primários: ocorrência de déficit neurológico isquêmico tardio (delayed ischemic neurological deficit (DIND)) e recuperação neurológica ruim, além das complicações e preferências de medicamentos.

Resultados

Nove ECRs foram incluídos nesta meta-análise. A maioria dos ECRs demonstra o efeito promissor da fibrinólise intratecal. A fibrinólise intracisternal mostrou-se significativamente eficaz na redução da incidência de delayed ischemic neurological deficit (DIND) (RR, 0,54; IC 95%, 0,32–0,91) e de eventos de recuperação neurológica ruim (RR, 0,65; IC 95%, 0,47–0,90). O impacto significativo nos eventos de delayed ischemic neurological deficit (DIND) também foi evidenciado na análise de subgrupos com a administração de uroquinase (RR, 0,31; IC 95%, 0,16–0,62). Embora a fibrinólise intraventricular não tenha alcançado significância estatística nos desfechos primários, os achados gerais sugerem um efeito benéfico considerando a escolha dos medicamentos administrados.

Conclusão

Esta meta-análise abrangente destaca os potenciais benefícios da fibrinólise intratecal na redução da ocorrência de delayed ischemic neurological deficit (DIND) e na melhora da recuperação neurológica em pacientes com aSAH. Os resultados promissores com a fibrinólise intracisternal e a administração de uroquinase justificam maior consideração nos protocolos de tratamento. Nossos achados contribuem com insights valiosos, orientando a tomada de decisões clínicas baseadas em evidências e promovendo avanços no manejo da aSAH.

Availability of Data and Materials

The data used and analyzed during the current study are available from the corresponding author upon reasonable request.


Authors' Contributions

JN, ARW, GAEK, TKPJ: data collection, data analysis, and manuscript preparation; JN: writing — original draft; JN, ARW, GAEK, TKPJ: copyediting, proofreading, and revision. All authors contributed to the conception and design of the study, critical revision of the manuscript, and final approval.


Supplementary Material



Publikationsverlauf

Eingereicht: 09. Januar 2025

Angenommen: 22. Mai 2025

Artikel online veröffentlicht:
08. Oktober 2025

© 2025. Sociedade Brasileira de Neurocirurgia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Revinter Publicações Ltda.
Rua Rego Freitas, 175, loja 1, República, São Paulo, SP, CEP 01220-010, Brazil