Rapidity of hematoma resolution after fibrinolytic therapy for intracerebral hemorrhage has a favorable effect on functional outcome

Fibrinolytic therapy with tissue plasminogen activator (rtPA) is considered a promising treatment option for intracerebral hemorrhage (ICH), but a large randomized controlled study (i.e., MISTIE III) failed to show a benefit for the long-term outcome. This study investigated whether the rapidity of hematoma volume reduction influences outcome of ICH-patients undergoing fibrinolytic therapy. Patients with supratentorial ICH with or without a secondary extension to the ventricular system receiving fibrinolytic therapy from 2010 to 2020 were retrospectively analyzed. Patients with primarily intraventricular hemorrhage were excluded. A catheter was placed into the hematoma via burr hole and by means of neuronavigation. After confirming a correct catheter position rtPA was injected through the catheter with subsequent passive drainage of the hematoma. Hematoma volume was measured initially and 24/48/72 hours after treatment and the relative volume reduction was calculated. The functional outcome at discharge was assessed using the modified Rankin scale (mRS) regarding a mRS of 4 or lower as favorable outcome. A total of 280 patients with mean age of 69.6 years and mean hematoma volume of 55.6 ml were analyzed. The odds of reaching favorable outcome were four-fold higher in patients with a volume reduction of more than 50% after 24 h (OR 4.23, 95%CI 3.05 to 5.66, p = 0.007). Patients with a residual volume of less than 30 ml after 24 h had a two-fold higher chance of having favorable outcome (OR 2.9, 95%CI 1.78 to 4.63, p < 0.0001). A fast volume reduction of at least 50% within 24 h resulted into a favorable outcome in ICH-patients undergoing fibrinolytic therapy. Not just the amount but also the rapidity of hematoma volume reduction seems to be an important factor for a good clinical result after fibrinolytic therapy.