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Intraventricular hemorrhage is a frequent complication of intracerebral hemorrhage and is independently associated with significant morbidity and mortality. Intraventricular fibrinolytic therapy is used with increasing frequency to accelerate clot clearance. We review the recent evidence and discuss the therapeutic benefits as well as the current concerns and limitations of fibrinolytic use in this setting.

19 patients were treated with streptokinase and (or) urokinase for primary thrombosis of the subclavian and (or) axillary vein (Paget-von-Schroetter-syndrome) of 2 to 28 days' duration. Phlebograms revealed significant improvement in 18 of the 19 patients (complete recanalization in 11, partial recanalization in 7). In those 17 patients whose symptoms had been present for up to 2 weeks the clinical outcome was entirely independent of the delay between the appearance of first symptoms and the start of fibrinolytic therapy, and even in the 2 patients wih an even longer delay complete recanalization was achieved in one (delay of 3 weeks) and partial recanalization in the other (delay of 4 weeks). However, since major clinical improvement occurs also spontaneously in most patients, a clear indication for fibrinolytic therapy exists only in particularly young patients and in those patients who depend on an absolutely perfect function of their upper extremities. In addition, the good results obtained with delayed fibrinolytic therapy justify extending this indication to those remaining patients in whom prior conservative management with elevation of the arm and anticoagulant therapy does not result in sufficient clinical improvement.

Two patients, aged 64 and 47 years, had a massive pulmonary embolism one day after cholecystectomy. Ultra-short fibrinolysis was undertaken with 1.5 million units of streptokinase. Both patients rapidly improved, with a fall in heart rate, pulmonary artery or central-venous pressure, and a rise in arterial pO2. There were no significant bleedings. Ultra-short fibrinolysis (maximally over one hour) can thus successfully lyse emboli--consisting of fresh plasminogen-rich coagulation thrombi in the early postoperative period--without re-opening wound- and capillary beds during this short period.

Entzundliche Pleuraergusse und Pleuraempyeme enstehen zumeist als Komplikation einer Pneumonie, seltener sind sie iatrogener Genese, z. B. als Folge thoraxchirurgischer Eingriffe. Die Behandlung orientiert sich vor allem am klinischen Bild, am Aspekt der Flussigkeit, an einigen Laborparametern, und dem Ansprechen auf die jeweils getroffenen Masnahmen. Die antibiotische Therapie richtet sich bis zum Erhalt genauerer mikrobiologischer Befunde nach der empirischen Wahrscheinlichkeit der verursachenden Erreger. Ahnlich wie bei Pneumonien muss beim ambulant erworbenen Erguss bzw. Empyem ein deutlich anderes Erregerspektrum berucksichtigt werden als bei nosokomialen Infektionen. Das Management eines Pleuraempyems sollte moglichst in interdisziplinarer Abstimmung zwischen Internisten bzw. Pneumologen und Thoraxchirurgen erfolgen. Die fur den Behandlungserfolg entscheidende Masnahme ist die fruhzeitige und effektive Drainage der Empyemhohle. Gekammerte Ergusse, die nicht prompt auf die konventionelle Drainage ansprechen, konnen uber etwa drei Tage zusatzlich einer intrapleuralen Fibrinolytika-Behandlung unterzogen werden. Effektivitat und Stellenwert dieser Masnahme unterliegen allerdings noch der Diskussion. Bei fehlenden Kontraindikationen und ortlicher Verfugbarkeit sollte die fruhzeitige Sanierung der Empyemhohle vorzugsweise durch die Video-assistierte Thorakoskopie (video-assisted thoracoscopic surgery, VATS) angestrebt werden. Pleural effusions of infectious origin usually present as a complication of pneumonia, or, more rarely, of thoracic surgical procedures. Treatment is based upon the clinical picture, the appearance of the pleural fluid, on certain laboratory parameters, and upon the success of therapeutic interventions. The initial antibiotic regimen should cover the causative organisms that may empirically be expected in the individual setting of the patient. Similar to the situation in pneumonias, the spectrum of organisms in community-acquired effusions or empyemas differs substantially from that in hosptial-acquired pleural infections. The management of pleural empyemas should follow an interdisciplinary strategy which involves the pulmologist and the thoracic surgeon. The single most important intervention is the early and effective drainage of the pleural cavity. Loculated effusions that do not promptly improve after drainage can addditionally be treated by a trial of intrapleural fibrinolysis for a period of approximately three days. However, the precise role of fibrinolytics in the setting of complicated pleural efffusions and empyemas remains to be better defined. Early definitive surgical treatment, preferentially by video-assisted thoracoscopic surgery (VATS), should be the goal in all patients who do not promptly respond to drainage and/or intrapleural fibrinolytic therapy and who qualify for a surgical intervention.

ZusammenfassungUnter dem Begriff des akuten Koronarsyndroms (ACS) werden die instabilen und somit lebensbedrohlichen Formen der klinisch manifesten koronaren Herzkrankheit zusammengefasst. Dies sind die instabile Angina pectoris, der Nicht-ST-Strecken-hebende (NSTEMI) und der ST-Strecken-hebende Myokardinfarkt (STEMI) sowie der plötzliche Herztod.Wichtigstes therapeutisches Ziel ist die rasche und vollständige Wiedereröffnung der eingeengten oder verschlossenen Koronararterie, um den Verlust an kontraktiler Muskelmasse zu minimieren. Unangefochtene Therapie der Wahl ist hierfür die primäre perkutane Koronarintervention (PCI), wenn diese innerhalb von zwei Stunden von einem erfahrenen Team vorgenommen werden kann. Da diese Vorausetzung in Deutschland nur an 20% der Myokardinfarkt-Patienten versorgenden Kliniken erfüllt ist, kommt der medikamentösen Therapie weiterhin eine große Bedeutung zu. Neben einer schnellen Primärversorgung ist auch die optimale gerinnungs- und aggregationshemmende Therapie während der Koronarintervention mit dem Primär- und Langzeiterfolg eng korreliert. Entsprechend den aktuellen Erkenntnissen ist es die Kombinationstherapie verschiedener Substanzen, die unter Berücksichtigung von Kontraindikationen das bestmögliche Ziel erreichen lässt.

Synergism between factor XII –4C>T and factor XIII Val34Leu polymorphisms in fibrinolytic therapy in acute myocardial infarction

To date, intraarterial lysis is a widely accepted form of treatment for femoropopliteal occlusions. However, the outcome of therapy has been difficult to predict. Therefore, the present study dealt with two parameters likely to influence the occlusion removal rate. These are the outflow condition distal of the occlusion, and the occlusion length. Fifty patients with subacute femoropopliteal occlusions were treated with intraarterial thrombolysis and, in case residual obstructions were left, with subsequent catheter dilation. Only "soft" occlusions that were probed by a guide wire and proved to be penetrable were chosen for treatment. The occlusion age was 3.79 +/- 4.57 weeks with 90% of cases in the range of 1 day to 6 weeks. Fibrinolytic therapy consisted of one to three one-hour series of 300,000 IU urokinase instillation directly into the occlusion material. The complete clearance rate was 34/50 = 68%. In successfully treated patients, both the pressure gradient (difference between systemic and ankle pressure) and the walking distance improved significantly. Most important factors for success or failure of treatment were the quality of calf outflow and the length of obstruction. Thus, patients with at least one calf artery open and an occlusion length of under 10 cm presented with an opening rate of 88.5%, whereas patients with no calf arteries patent and an occlusion length over 20 cm presented with an opening rate of only 20%. The age of the occlusions, all penetrable by a guide wire prior to treatment, did not influence the rate of recanalization. Intraarterial short-term and high-dose urokinase infusion is an excellent form of treatment for subacute femoropopliteal occlusions. Especially good results with a 88.5% clearance rate were achieved in patients who presented with at least one calf artery open and an occlusion length below 10 cm.

Objective Frame-based stereotactic puncture and catheter placement followed by fibrinolytic therapy and drainage is one treatment option in the management of spontaneous intracerebral hemorrhage (sICH). This minimally invasive procedure could even be simplified by frameless stereotaxy. The authors present their experiences with frameless stereotactic image-guided catheter placement for lysis and drainage of sICH, with emphasis on technical aspects. Method In 27 patients with sICH, an infrared-based frameless stereotactic device was used for selecting trajectory and target point of hematoma drainage. A trajectory along the main axis of the hematoma was considered to be optimal for fibrinolytic therapy. An articulated arm served to maintain the predetermined trajectory during surgery and to guide catheter advancement. Clot lysis with recombinant tissue plasminogen activator (rt-PA) was initiated after radiological confirmation of correct catheter positioning. Results In all cases, selection of the optimal trajectory was not restricted by the frameless stereotactic device. In 25 of the 27 patients, the catheter was placed accurately along the predetermined trajectory into the target point. In two patients, the catheter was positioned at the lateral margin of the hematoma, excluding fibrinolytic therapy in one case. In 24 of 27 patients, the mean hematoma volume could be reduced from initially 52 ml to 17 ml in an average of two days. Hematoma enlargement following rt-PA injection was observed in two patients. Further complications were culture negative pleocytosis of cerebrospinal fluid in two and meningitis in one patient. Conclusion Hematoma puncture and catheter placement for fibrinolytic therapy could be achieved with high accuracy and safety using frameless stereotaxy. This method allows unrestricted trajectory selection with catheter positioning along the main hematoma axis. Further studies are required to investigate if frameless stereotactic puncture and clot lysis could contribute to improve the outcome of patients with sICH.

Seventy-three patients with vascular occlusions in the pelvis or lower limbs and three patients with upper limb lesions were treated by local low dose fibrinolysin, with strict control of any possible bleeding tendencies. Adequate recanalisation was obtained in 56 patients (73.6%). In ten patients, the occlusion recurred while the patient was still in hospital. After four to six months, 37 of the 56 (67%) of the vessels were still patent. In 18 patients, peripheral emboli resulted in some deterioration, but in 15 of these cases this could be treated successfully by operation. The methods and indications of local fibrinolysis therapy and the problems associated with it are discussed.