Ventricular Catheter Location and the Clearance of Intraventricular Hemorrhage

Abstract

Background There is no consensus regarding optimal position of external ventricular drain (EVD) with regard to clearance of intraventricular hemorrhage (IVH). Objective To assess the hypothesis that EVD laterality may influence the clearance of blood from the ventricular system, with and without administration of thrombolytic agent. Methods The EVD location was assessed in 100 patients in two CLEAR Phase II trials assessing the safety, and dose optimization of thrombolysis through the EVD to accelerate the clearance of obstructive IVH. Laterality of catheter was correlated with clearance rates. Results Clearance of IVH over the first 3 days was significantly greater when thrombolytic was administered as compared to placebo, regardless of catheter laterality (p < 0.005, CI −14.0, −4.14 for contralateral EVD and CI −24.7, −5.44 for ipsilateral EVD, respectively). When thrombolytic was administered, there was a trend of more rapid clearance of total IVH through an EVD placed on the side of dominant intraventricular blood as compared to an EVD on the side with lesser blood (P = 0.09; CI −9.62, 0.69). This was not true when placebo was administered. Clearance of 3rd and 4th ventricular blood was unrelated to EVD laterality. Conclusion It is possible that placement of EVD may be optimized to enhance the clearance of total IVH if lytic agents are used. Catheters on either side can clear the 3rd and 4th ventricles with equal efficiency.

Clearing bloody cerebrospinal fluid

“…Webb et al [21] observed a faster reduction in IVH score (clearance to 50%) in all assessed regions with increasing rtPA dose. The influence of location of EVD on clot resolution in CLEAR-IVH was assessed by Jaffe et al [29]. Those findings confirm some aspects reported in a recently published nonrandomized study, which compared between a dosing of 1 mg rtPA every 8 h (n ¼ 22) and 4 mg rtPA every 12 h (n ¼ 32) in a cohort of patients selected by similar inclusion criteria, as in CLEAR-IVH [28].…”

Resolution of Intraventricular Hemorrhage Varies by Ventricular Region and Dose of Intraventricular Thrombolytic

“…‘Ipsilateral’ or ‘contralateral’ ventricles were defined relative to catheter-associated rtPA administration, as the impact of IVH and ICH laterality has been reported elsewhere. 10 AW, SM and NU independently scored CLEAR-IVH: Safety scans, whilst CLEAR-IVH: Dose-Finding scans were scored by AW and DH. ‘Stability’ CT was the first scan with no catheter-tract hemorrhage or ICH growth >5cc.…”

Early Quantification of Hematoma Hounsfield Units on Noncontrast CT in Acute Intraventricular Hemorrhage Predicts Ventricular Clearance after Intraventricular Thrombolysis

“…Associations between HU quantification and change in IVH volumes reflect the most accurate assessment methods available but may have been affected by disparities in sampling, patient age, and time of EVD placement. Numerous factors have been shown to influence clearance rates of intraventricular blood after rtPA administration, including the location of the external ventricular drain, 16 bilateral-versus-single EVD, 17 the location of intraventricular blood, dose of thrombolytic, 18 and serum and CSF components. Our investigation examined the radiographic characteristics that complement these data.…”