Comparison of rebleeding risk after navigation-guided catheterization and thrombolytic irrigation using tPA or urokinase in intracerebral hemorrhage

Minimally invasive catheter-based evacuation is increasingly used for spontaneous intracerebral hemorrhage (ICH). Urokinase and tissue plasminogen activator (tPA) are used for intracatheter thrombolytic irrigation; however, direct comparative data on their safety, particularly regarding rebleeding risk, remain limited. This study aimed to compare rebleeding risk and early outcomes between urokinase and tPA after navigation-guided catheterization. We retrospectively analyzed adults with spontaneous supratentorial ICH who underwent stereotactic, navigation-guided catheter placement followed by scheduled intracavitary thrombolysis between January 2018 and December 2023. Patients received either urokinase or tPA. The primary outcome was rebleeding, defined as hematoma expansion or recurrence on imaging with neurological deterioration. Secondary outcomes were hematoma volume change from baseline to day 4 and short-term changes in modified Rankin Scale (mRS) and Glasgow Coma Scale (GCS). Penalized logistic regression, multivariable linear regression, and ordinal logistic regression models were used to adjust for baseline imbalances and evaluate radiologic and short-term functional outcomes. Eighty patients were included (urokinase, n = 35; tPA, n = 45). tPA-treated patients presented with higher initial systolic blood pressure and tended to have larger baseline hematoma volumes. Rebleeding occurred in 12/45 patients (26.7%) in the tPA group versus 2/35 (5.7%) in the urokinase group ( p = 0.032), and the presence of concurrent intraventricular hemorrhage (IVH) was a potent risk factor. After adjustment for concurrent IVH, symptom onset-to-surgery time, and baseline hematoma volume using a penalized multivariable model, tPA use remained associated with rebleeding (adjusted odds ratio,5.03; 95% confidence interval,1.12–22.64; p = 0.035). Mean hematoma volume reduction by day 4 was similar between groups, although volume change was more variable in the tPA group. Early shifts in mRS and GCS favored urokinase. In catheter-based minimally invasive treatment of spontaneous supratentorial ICH, urokinase was associated with a lower risk of rebleeding and more favorable early neurological outcomes than tPA, despite comparable mean hematoma reduction.