RT Journal Article SR Electronic T1 Early cisternal fibrinolysis is more effective than rescue spasmolysis for the prevention of delayed infarction after subarachnoid haemorrhage JF Stroke and Vascular Neurology JO Stroke Vasc Neurol FD BMJ Publishing Group Ltd SP svn-2021-001146 DO 10.1136/svn-2021-001146 A1 Roland Roelz A1 Christian Scheiwe A1 Jürgen Grauvogel A1 Istvan Csok A1 Volker Arnd Coenen A1 Jürgen Beck A1 Peter C Reinacher YR 2021 UL http://svn.bmj.com/content/early/2021/11/08/svn-2021-001146.abstract AB Background To compare the efficacy of two different concepts of cisternal therapy—PREVENTIVE fibrinolysis plus on-demand spasmolysis versus RESCUE spasmolysis—for the prevention of cerebral vasospasm (CVS) and delayed cerebral infarction (DCI) in patients with aneurysmal subarachnoid haemorrhage (aSAH).Methods Retrospective analysis of 84 aSAH patients selected for cisternal therapy for DCI prevention. 66 high-risk patients received PREVENTIVE cisternal therapy to enhance blood clearance. Either stereotactic catheter ventriculocisternostomy (STX-VCS) or intraoperative placement of a cisterno-ventriculostomy catheter (CVC), followed by fibrinolytic cisternal lavage using urokinase was performed. In case of vasospasm, nimodipine was applied intrathecally. 22 low-risk patients who developed CVS against expectations were selected for STX-VCS as RESCUE intervention for cisternal spasmolysis with nimodipine. Rates of DCI and mean flow velocities of daily transcranial Doppler (TCD) ultrasonographies were evaluated.Results Despite a higher prespecified DCI risk, patients selected for PREVENTIVE intervention primarily aiming at blood clearance had a lower DCI rate compared with patients selected for intrathecal spasmolysis as a RESCUE therapy (11.3% vs 18.2%). After intrathecal treatment onset, CVS (TCD>160 cm/s) occurred in 45% of patients with PREVENTIVE and 77% of patients with RESCUE therapy (p=0.013). A stronger response of CVS to intrathecal nimodipine was observed in patients with PREVENTIVE intervention as the mean CVS duration after start of intrathecal nimodipine was 3.2 days compared with 5.8 days in patients with RESCUE therapy (p=0.026).Conclusions PREVENTIVE cisternal therapy directed at blood clearance is more effective for the prevention of CVS and delayed infarction compared with cisternal RESCUE spasmolysis.Trial registration number DRKS00016532.Data are available on reasonable request. Data from this study are available on reasonable request and in accordance with European data protection rules.