Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature

Abstract

Severe intraventricular hemorrhage caused by extension from subarachnoid hemorrhage or intracerebral hemorrhage leads to hydrocephalus and often to poor outcome. We conducted a systematic review to compare conservative treatment, extraventricular drainage, and extraventricular drainage combined with fibrinolysis. We carried out a search in Medline of the literature between January 1966 and December 1998 and an additional hand-search from January 1990 to December 1998. Pharmaceutical companies were contacted to gather unpublished data. We reviewed the reference lists of all relevant articles. Two authors independently assessed eligibility of the studies and extracted data on characteristics of study design, patients, and treatment. Patients with primary intraventricular hemorrhage were excluded. Main outcome measures were death and poor outcome (defined as death or dependency) at the end of follow-up. No randomized clinical trial has yet been conducted so far, and we therefore reviewed only observational studies. The case fatality rate for conservative treatment (ten studies) was 78%. For extraventricular drainage (seven studies) it was 58% [relative risk versus conservative treatment (RR) 0.74; 95% confidence interval (CI) 0.55-0.99]. For extraventricular drainage with fibrinolytic agents (five studies) the case fatality rate was 6% (RR 0.08; 95% CI 0.02-0.24). The poor outcome rate for conservative treatment was 90%, that for extraventricular drainage 89% (RR 0.98; 95% CI 0.75-1.30) and that for extraventricular drainage with fibrinolytic agents 34% (RR 0.38; 95% CI 0.21-0.68). All RR values remained essentially the same after adjusting for age, sex, World Federation of Neurological Surgeons scale, study design, and year of publication for the studies that provided these data. Outcome is thus poor in patients with intraventricular extension of subarachnoid or intracerebral hemorrhage. This meta-analysis suggests that treatment with ventricular drainage combined with fibrinolytics may improve outcome for such patients, although this impression is derived only from an indirect comparison between observational studies. A randomized clinical trial is warranted.

Rapid Pore Cranial Drilling With External Ventricular Drainage for Treatment of Intraventricular Hemorrhage: A 36-Year Case Series

“…The statistic data have shown that the case fatality rate for conservative treatment of severe IVH was 78%, and it was 58% for EVD performed by conventional drilling technique. 1 In our study, the mortality rate of 3773 cases with rapid pore drilling was only 24.8%, and the mortality rate for patients with severe conditions such as aneurysm rupture and cerebral arteriovenous hemorrhage was slightly higher (.30%), yet still significantly lower than the historical comparator. However, this comparison was made from indirect observational studies using historic data.…”

Risk factors for hydrocephalus requiring external ventricular drainage in patients with intraventricular hemorrhage

“…22 Although IVH per se may be detrimental for neurological recovery, there is no definite proof that EVD has a beneficial effect in patients without symptomatic hydrocephalus. 18 Our results indicate that it is reasonable to observe patients with IVH (even those with panventricular involvement) as long as they do not have symptomatic hydrocephalus. Yet, these patients must be monitored closely, especially if they have very extensive IVH, coma without hydrocephalus, or dilation of the fourth ventricle.…”

Local Fibrinolysis in Surgical Treatment of Non-Traumatic Intracranial Hemorrhages

“…Помимо системного фибринолиза при ишемическом инсульте и локального фибринолиза при геморрагическом ин-сульте с 90-х гг. стало развиваться принципиально новое направление использования фибринолитиков -интрате-кальный фибринолиз при субарахноидальных и внутри-желудочковых кровоизлияниях (ВЖК) нетравматическо-го генеза [10][11][12][13][14][15].…”