Emergency Free-Hand Bedside Catheter Evacuation of Large Intracerebral Hematomas Following Thrombolysis for Ischemic Stroke: A Case Series

  • Juergen BardutzkyEmail author
  • Mukesch Shah
  • Johann Lambeck
  • Stephan Meckel
  • Wolf-Dirk Niesen
Original Work



Symptomatic intracerebral hemorrhage (sICH) following systemic thrombolysis for ischemic stroke is often devastating, and open surgical evacuation is considered dangerous due to the increased risk of perioperative bleeding, and stereotactic placement of a catheter is too time-consuming. We therefore evaluated the feasibility of a free-hand bedside catheter technique for emergency hematoma evacuation.


Patients who had a supratentorial sICH after thrombolysis, a hematoma volume > 30 ml, and an ensuing reduction in vigilance were consecutively treated with acute minimally invasive catheter hematoma evacuation. Catheter insertion and trajectory were planned via 3D-reconstructed computed tomography (CT) scan, and free-hand insertion of an external ventricular catheter into the core of the hematoma was performed bedside, followed by careful blood aspiration. Cranial CT was used to verify catheter position and residual hematoma volume. In cases, where the residual volume exceeded 15 ml, urokinase (5000 IE) was administered into the clot every 6 h until the volume decreased to < 15 ml.


In all six patients, catheter aspiration immediately reduced hematoma volume by 77%, from 73 ± 20 ml to 17 ± 16 ml (p = 0.028). In four patients, the hematoma was almost completely removed (< 10 ml) by singular aspiration. In the remaining two patients with a residual hematoma size > 15 ml, consecutive urokinase application resulted in a further reduction to 1 ml and 15 ml, respectively, after 30 h. The median National Institues of Health Stroke Scale/Score after sICH was 19.5 points, rapidly decreasing to 11 after catheter aspiration (p = 0.027), and further improving to 4 at discharge. No procedure-related complications were observed.


Emergency free-hand bedside catheter aspiration is a reasonable option for hematoma evacuation in large thrombolysis-associated sICH when performed by experienced neurosurgeons. Larger studies would help in determining the generalizability of our findings to other centers and assessing their impact on functional outcome.


Thrombolysis Intracerebral hematoma Minimally invasive surgery Urokinase 




Author contributions

JB and WDN contributed to preparing and writing of the manuscript, data acquisition. MS contributed to preparing manuscript, preparing and analysis of images. JL contributed to preparing the manuscript, statistics. SM contributed to preparing of the manuscript and images.

Source of support


Conflict of interest


Ethical approval

The study was approved by our local ethics committee (registration number 161/19).


  1. 1.
    Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–110.CrossRefGoogle Scholar
  2. 2.
    Wahlgren N, Ahmed N, Dávalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369(9558):275–82.CrossRefGoogle Scholar
  3. 3.
    Whiteley WN, Emberson J, Lees KR, et al. Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis. Lancet Neurol. 2016;15:925–33.CrossRefGoogle Scholar
  4. 4.
    Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768–74.CrossRefGoogle Scholar
  5. 5.
    Hill MD, Buchan AM. Canadian Alteplase for Stroke Effectiveness Study (CASES) Investigators. Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study. CMAJ. 2005;172(10):1307–12.CrossRefGoogle Scholar
  6. 6.
    Khatri P, Wechsler LR, Broderick JP. Intracranial hemorrhage associated with revascularization therapies. Stroke. 2007;38:431–40.CrossRefGoogle Scholar
  7. 7.
    Hemphill JC 3rd, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46:2032–60.CrossRefGoogle Scholar
  8. 8.
    Yaghi S, Eisenberger A, Willey JZ. Symptomatic intracerebral hemorrhage in acute ischemic stroke after thrombolysis with intravenous recombinant tissue plasminogen activator: a review of natural history and treatment. JAMA Neurol. 2014;71(9):1181–5.CrossRefGoogle Scholar
  9. 9.
    Deininger MH, Adam A, Van Velthoven V. Bedside catheter evacuation of predominantly isolated traumatic supratentorial hemorrhage J Trauma. 2008;65:1194–9.PubMedGoogle Scholar
  10. 10.
    Volbers B, Staykov D, Wagner I, et al. Semi-automatic volumetric assessment of perihemorrhagic edema with computed tomography. Eur J Neurol. 2011;18:1323–8.CrossRefGoogle Scholar
  11. 11.
    Goldstein JN, Marrero M, Masrur S, et al. Management of thrombolysis-associated symptomatic intracerebral hemorrhage. Arch Neurol. 2010;67(8):965–9.CrossRefGoogle Scholar
  12. 12.
    Yaghi S, Boehme AK, Dibu J, et al. Treatment and outcome of thrombolysis-related hemorrhage: a multicenter retrospective study. JAMA Neurol. 2015;72(12):1451–7.CrossRefGoogle Scholar
  13. 13.
    Mahaffey KW, Granger CB, Sloan MA, et al. Neurosurgical evacuation of intracranial hemorrhage after thrombolytic therapy for acute myocardial infarction: experience from the GUSTO-I trial. Global Utilization of Streptokinase and tissue-plasminogen activator (tPA) for Occluded Coronary Arteries. Am Heart J. 1999;138(3 Pt 1):493–9.CrossRefGoogle Scholar
  14. 14.
    Deininger MH, Adam A, Van Velthoven V. Free-hand bedside catheter evacuation of cerebellar hemorrhage. Minim Invasive Neurosurg. 2008;51(1):57–60.CrossRefGoogle Scholar
  15. 15.
    Hersh EH, Gologorsky Y, Chartrain AG, Mocco J, Kellner CP. Minimally Invasive Surgery for Intracerebral Hemorrhage. Curr Neurol Neurosci Rep. 2018;18(6):34.CrossRefGoogle Scholar
  16. 16.
    Naff NJ, Hanley DF, Keyl PM, et al. Intraventricular thrombolysis speeds blood clot resolution: results of a pilot, prospective, randomized, double-blind, controlled trial. Neurosurgery. 2004;54(3):577–83.CrossRefGoogle Scholar
  17. 17.
    Hanley DF, Lane K, McBee N, et al. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet. 2017;389:603–11.CrossRefGoogle Scholar
  18. 18.
    Li Y, Yang R, Li Z, et al. Urokinase vs tissue-type plasminogen activator for thrombolytic evacuation of spontaneous intracerebral hemorrhage in basal ganglia. Front Neurol. 2017;8:371–8.CrossRefGoogle Scholar
  19. 19.
    Hanley DF, Thompson RE, Rosenblum M, et al. Efficacy and safety of minimally invasive surgery with thrombolysis in intracerebral haemorrhage evacuation (MISTIE III): a randomised, controlled, open-label, blinded endpoint phase 3 trial. Lancet. 2019;393:1021–32.CrossRefGoogle Scholar
  20. 20.
    Rohde V, Uzma N, Rohde I, St Clair E, Samadani U. Fibrinolytic therapy versus craniotomy for anticoagulant-associated intracerebral hemorrhage. Clin Neurol Neurosurg. 2009;111(6):518–22.CrossRefGoogle Scholar
  21. 21.
    Malinova V, Schlegel A, Rohde V, Mielke D. Catheter placement for lysis of spontaneous intracerebral hematomas: does a catheter position in the core of the hematoma allow more effective and faster hematoma lysis? Neurosurg Rev. 2017;40:397–402.CrossRefGoogle Scholar
  22. 22.
    Paramore CG, Turner DA. Relative risks of ventriculostomy infection and morbidity. Acta Neurochir (Wien). 1994;127:79–84.CrossRefGoogle Scholar
  23. 23.
    Gaberel T, Magheru C, Parienti JJ, Huttner HB, Vivien D, Emery E. Intraventricular fibrinolysis versus external ventricular drainage alone in intraventricular hemorrhage: a meta-analysis. Stroke. 2011;42(10):2776–81.CrossRefGoogle Scholar
  24. 24.
    Gaberel T, Montagne A, Lesept F, et al. Urokinase versus Alteplase for intraventricular hemorrhage fibrinolysis. Neuropharmacology. 2014;85:158–65.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2019

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of Freiburg Medical SchoolFreiburgGermany
  2. 2.Department of NeurosurgeryUniversity of Freiburg Medical SchoolFreiburgGermany
  3. 3.Department of NeuroradiologyUniversity of Freiburg Medical SchoolFreiburgGermany

Personalised recommendations