Intraventricular Fibrinolysis and Lumbar Drainage for Ventricular Hemorrhage

Staykov, Dimitre; Huttner, Hagen B.; Struffert, Tobias; Ganslandt, Oliver; Doerfler, Arnd; Schwab, Stefan; Bardutzky, Juergen

doi:10.1161/strokeaha.109.551945

Cited by 89 publications

(89 citation statements)

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“…Those data were compared with data from a previously published prospective study 3 in which a higher single dose of 4 mg rtPA and a dosing interval of 12 hours with a maximum cumulative dose of 20 mg rtPA (high-dose IVF group) were used.…”

Section: Methodsmentioning

confidence: 99%

“…3 The decision to place 1 or bilateral EVDs was left at the discretion of the treating neurosurgeon. The only difference between the 2 groups consisted of the rtPA dose and the dosing interval used for IVF.…”

Section: Methodsmentioning

confidence: 99%

“…Based on institutional experience, we initially used a dosing regimen for IVF consisting of 4-mg single doses of recombinant tissue plasminogen activator (rtPA) administered every 12 hours up to a maximum cumulative dose of 20 mg. 3 After the results of the Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR-IVH) dose finding trial have been reported, 4 we changed our institutional protocol in accordance with the trial findings for the optimal IVF dosage and interval (1 mg every 8 hours, maximum cumulative dose 12 mg). The aim of the present study was to compare the effect on clot resolution and the safety profiles of the 2 IVF dosing regimens.…”

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confidence: 99%

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Dose Effect of Intraventricular Fibrinolysis in Ventricular Hemorrhage

Staykov

Wagner²,

Volbers³

et al. 2011

Stroke

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Background and Purpose-The aim of the current study was to investigate the dose-dependent efficacy of intraventricular fibrinolysis (IVF) in patients with severe intraventricular hemorrhage (IVH). Methods-Patients with intracerebral hemorrhage, severe IVH, and obstructive hydrocephalus with the need for external ventricular drainage were treated with IVF through external ventricular drainage. The time course of IVH resolution and the safety profile were compared between patients treated with high-dose IVF (4 mg alteplase every 12 hours, maximum 20 mg; nϭ32) and low-dose IVF (1 mg alteplase every 8 hours, maximum 12 mg; nϭ22). CT scans on Days 1 to 4, 7Ϯ1 and 10Ϯ1 after admission, were analyzed volumetrically. Outcome was assessed after 3 months. Results-The overall effect of IVF dosage was not significantly different between the 2 groups (Fϭ1.3, Pϭ0.25). The course of IVH volume in the third and fourth ventricles was similar with high-and low-dose IVF. High-dose IVF resulted in lower total IVH volumes on Days 7 (4.4Ϯ4.2 mL versus 8.8Ϯ8.1 mL; Pϭ0.01) and 10 (1.4Ϯ2.8 mL versus 4.9Ϯ65.8 mL; Pϭ0.005). Total clot half-life was 78Ϯ43 hours in the low-dose and 56Ϯ25 hours in the high-dose group (Pϭ0.02). One asymptomatic ventricular bleeding, 2 cases of ventriculitis, and 1 death due to pulmonary embolism occurred in the high-dose group. There was no difference in outcome at 3 months. Conclusions-Low-dose IVF (3 mg alteplase/day) has a similar effect on IVH clearance from the third and fourth ventricles and a similar safety profile when compared with high-dose IVF (8 mg alteplase/day).

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

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Dose Effect of Intraventricular Fibrinolysis in Ventricular Hemorrhage

Staykov

Wagner²,

Volbers³

et al. 2011

Stroke

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“…22 In patients with significant IVH, intraventricular thromboly sis with rtPA was administered per the Clot Lysis: Evalu ating Accelerated Resolution of IVH (CLEAR IVH) pro tocol to facilitate clot resolution. 7,9,24 Intracranial pressure was recorded at least hourly in all patients with EVDs. Drain height was adjusted as needed based on the patient's neurological status and to maintain a goal ICP between 0 and 20 mm Hg.…”

Section: Placement and Management Of The Evdmentioning

confidence: 99%

Predictors of long-term shunt-dependent hydrocephalus in patients with intracerebral hemorrhage requiring emergency cerebrospinal fluid diversion

Zacharia¹,

Vaughan²,

Hickman³

et al. 2012

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Object Intracerebral hemorrhage (ICH) is frequently complicated by acute hydrocephalus, necessitating emergency CSF diversion with a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. It is unclear what factors may predict the need for ventricular shunt placement in this patient population. Methods The authors performed a retrospective analysis of a prospective database (ICH Outcomes Project) containing patients with nontraumatic ICH admitted to the neurological ICU at Columbia University Medical Center between January 2009 and September 2011. A multiple logistic regression model was developed to identify independent predictors of shunt-dependent hydrocephalus after ICH. The following variables were included: patient age, admission Glasgow Coma Scale score, temporal horn diameter on admission CT imaging, bicaudate index, admission ICH volume and location, intraventricular hemorrhage volume, Graeb score, LeRoux score, third or fourth ventricle hemorrhage, and intracranial pressure (ICP) and ventriculitis during hospital stay. Results Of 210 patients prospectively enrolled in the ICH Outcomes Project, 64 required emergency CSF diversion via placement of an external ventricular drain and were included in the final cohort. Thirteen of these patients underwent permanent ventricular CSF shunting prior to discharge. In univariate analysis, only thalamic hemorrhage and elevated ICP were significantly associated with the requirement for permanent CSF diversion, with p values of 0.008 and 0.033, respectively. Each remained significant in a multiple logistic regression model in which both variables were present. Conclusions Of patients with ICH requiring emergency CSF diversion, those with persistently elevated ICP and thalamic location of their hemorrhage are at increased odds of developing persistent hydrocephalus, necessitating permanent ventricular shunt placement. These factors may assist in predicting which patients will require permanent CSF diversion and could ultimately lead to improvements in the management of this disorder and the outcome in patients with ICH.

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“…7,8 Finally, blood and its breakdown products cause inflammation of the ependymal layer and the subependymal brain tissue, 5,6,9 and also inflammation and fibrosis of the arachnoid mater, thereby leading to a delayed communicating hydrocephalus. 10 Considering those pathomechanisms, there seems to be a clear rationale for the fast removal of blood and blood breakdown products from the ventricular system. Intraventricular fibrinolysis (IVF), that is, the administration of fibrinolytic agents as recombinant tissue plasminogen activator (rtPA) into the ventricles, seems to be an emerging and promising treatment strategy, 11 which is currently being investigated in a large phase III multicenter trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage [CLEAR-III]).…”

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Intraventricular Fibrinolysis Does Not Increase Perihemorrhagic Edema After Intracerebral Hemorrhage

Volbers

Wagner

Willfarth

et al. 2013

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PHE may play a role as a source of additional mass effect, especially in large ICH, and thereby lead to neurological Background and Purpose-Additional intraventricular hemorrhage leads to higher mortality and worse functional outcome after intracerebral hemorrhage (ICH). Intraventricular fibrinolysis (IVF) with recombinant tissue plasminogen activator (rtPA) is an emerging treatment strategy for such patients. However, experimental studies suggest that rtPA may exert proedematous effects and lead to increased perihemorrhagic edema (PHE) after ICH. We aimed to compare the course of PHE after ICH between patients who received IVF with rtPA and controls matched for ICH volume. Methods-Patients were identified retrospectively from our institutional ICH database. Sixty-four patients with ICH and intraventricular hemorrhage who were treated with IVF were compared with 64 controls, who did not receive IVF, matched for ICH volume. The course of PHE was assessed on computed tomography scans (day 1, days 2 and 3, days 4-6, 7-9, and 10-12) using a threshold-based semiautomatic volumetric algorithm. Relative PHE was calculated as a ratio of PHE volume and initial ICH volume. Results-The matching algorithm resulted in similar mean ICH volumes in both groups (20.01±17.5 mL, IVF vs 20.08±17.1 mL, control). Intraventricular hemorrhage volume was larger in the IVF group (26.8±19.2 mL vs 9.2±13.4 mL). The mean total rtPA dose used for IVF was 8±6 mg. PHE increased over time in both groups until day 12. At all investigated time points, there was no significant difference in relative PHE between the IVF group and controls (F=0.39; P=0.844). Conclusions-IVF

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Intraventricular Fibrinolysis and Lumbar Drainage for Ventricular Hemorrhage

Cited by 89 publications

References 34 publications

Dose Effect of Intraventricular Fibrinolysis in Ventricular Hemorrhage

Dose Effect of Intraventricular Fibrinolysis in Ventricular Hemorrhage

Predictors of long-term shunt-dependent hydrocephalus in patients with intracerebral hemorrhage requiring emergency cerebrospinal fluid diversion

Intraventricular Fibrinolysis Does Not Increase Perihemorrhagic Edema After Intracerebral Hemorrhage

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