Influence of intraventricular fibrinolytic therapy with rt‐PA on the long‐term outcome of treated patients with spontaneous basal ganglia hemorrhage: a case–control study

Abstract

Over the recent years, fibrinolytic agents have been tested for intraventricular clot fibrinolysis (IVF). Compared with patients who did not receive IVF, administration of rt-PA induces rapid resorption of intraventricular blood and normalization of cerebrospinal fluid (CSF) circulation resulting in a reduced 30-day mortality and beneficial short-term outcome after 3 months. Our objective was to analyze possible influences of IVF on the long-term outcome after 12 months. Based on a prospective data base, patients with ganglionic supratentorial hematoma with additional intraventricular hemorrhage and occlusive hydrocephalus (n = 135) were isolated. Twenty-seven patients received IVF. To design a case-control study, we carefully matched 22 controls without IVF with regard to hematoma volume, Graeb score, Glasgow Coma Scale on admission and age (five patients remained unmatchable). We determined clinical and imaging parameters by reviewing the medical records and CT scans of all included patients. Outcome after 12 months was evaluated using the modified Rankin scale (mRS). One multivariate regression analysis was performed to determine predisposing factors for outcome. IVF significantly reduced Graeb score during treatment (eight on admission, three after IVF, one prior to discharge in the treated group versus 8/6/2 in patients without IVF). In patients with IVF requirement, a second external ventricular drainage (EVD) and a ventriculoperitoneal (VP) shunt were reduced (P = 0.08) and the incidence of a lumbar drainage was significantly higher (P < 0.01), whilst the overall time of extra-corporal CSF drainage was comparable. EVD associated complications were equal in both groups. Overall long-term outcome was poor but no significant differences were found between patients with and without IVF (mRS 4-6: 12/22 (54%) in patients with and 13/22 (59%) in patients without IVF; P = 0.81). The five excluded patients with IVF were similar to the 22 included ones with respect to imaging findings and outcome. The multivariate analysis revealed age and baseline hematoma volume, but not IVF to significantly impact the outcome. In accordance with previous studies, IVF hastened clot lysis and reduced the need for repeated EVD exchanges and permanent shunting. However, despite these advantages, IVF did not influence long-term outcome after 12 months. The results of the prospective randomized trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) need to be awaited.

Intraventricular Fibrinolysis and Lumbar Drainage for Ventricular Hemorrhage

“…The dosage and timing regimen of rtPA application was based on previous institutional experience. 12,15 …”

“…The duration of catheter clamping and the interval between clamping attempts of the LD were based on previous institutional experience. 8,12,15 …”

“…A permanent VP shunt was indicated before insertion of a third EVD (ie, at Day 20) or if LD clamping was unsuccessful for Ͼ10 days. 8,15 Neuroimaging Data Routine cranial CT scans were performed on admission, immediately after EVD placement, and then daily up to Day 4, on Day 7, and Day 10 after admission. During IVF, CT controls were scheduled shortly before (2Ϯ2 hours) the next scheduled rtPA application.…”

External ventricular drainage alone versus endoscopic surgery for severe intraventricular hemorrhage: a comparative retrospective analysis on outcome and shunt dependency

“…Many studies have demonstrated the independent effect of IVH on mortality. [16][17][18][19][20] Neuroendoscopy may offer some advantages over more traditional surgical approaches such as EVD placement and intraventricular fibrinolysis and should be considered the gold-standard approach, especially when dealing with elderly patients in poor general health.…”

“…4,8,16,20,26,36,37,51 Intraventricular blood brings about multiple noxious effects 10,13 on the brain causing impairment of CSF circulation, 29 intracranial hypertension, 19 and acute 14 or delayed hydrocephalus. 15 Mortality estimates for IVH range from 50% to 80%.…”