Intraventricular streptokinase increases cerebrospinal fluid D dimer in preterm infants with posthaemorrhagic ventricular dilatation

Dynamic evolution of D-dimer level in cerebrospinal fluid predicts poor outcome in patients with spontaneous intracerebral hemorrhage combined with intraventricular hemorrhage

The risk of mortality in patients with intracerebral hemorrhage (ICH) significantly increases when complicated by intraventricular hemorrhage (IVH). We hypothesize that serial measurement of cerebrospinal fluid (CSF) D-dimer levels in patients with both ICH and IVH may serve as an early marker of IVH severity. We performed a prospective study of 43 consecutive ICH patients combined with IVH and external ventricular drainage placement admitted in our institution from 2005-2006. IVH severity (Graeb score) and fibrinolytic activity were evaluated continuously for 7days using CT scans and CSF D-dimer levels. The primary outcome was 30day mortality. Overall 30day mortality was 26% (n=11), with eight deaths (72.7%) after 3days (D3). Graeb score and CSF D-dimer on admission (D0) were not significantly different between survivors and non-survivors. The temporal profiles of both parameters were distinctly different, with a downward trend in survivors and an upward trend in non-survivors. A mortality rate of 54% was observed between D0-D3 when both scores increased during this interval. In contrast, the mortality was only 4% when both measures decreased during this interval. Early phase (D0-D3) CSF D-dimer or Graeb score change demonstrated high sensitivity of 88% and specificity of 81% when predicting 30day mortality. Early phase CSF D-dimer change in patients with both ICH and IVH is accurate in predicting mortality and may be utilized as a cost-effective surrogate indicator of IVH severity. Serial monitoring of CSF D-dimer dynamic changes is useful for early identification of patients with hematoma progression and poor outcome.

Intraventricular administration of recombinant tissue plasminogen activator for intraventricular hemorrhage in the newborn

Intraventricular hemorrhage remains associated with high mortality and morbidity. Its most serious complication is posthemorrhagic hydrocephalus caused by multiple small blood clots obstructing the arachnoid villi. We treated three newborn infants (one term, two preterm) with posthemorrhagic hydrocephalus using recombinant tissue plasminogen activator, a thrombolytic agent, injected into the ventricles with a spinal needle. Sufficient fibrinolysis was achieved in these preterm patients. They all survived, and shunt surgery was only required in one. No adverse reactions or side effects have occurred. Intraventricular fibrinolysis with tissue plasminogen activator seems to be safe and effective for the treatment of intraventricular hemorrhage. However, controlled studies are needed for assessing treatment efficiency.

Phase 1 trial of prevention of hydrocephalus after intraventricular hemorrhage in newborn infants by drainage, irrigation, and fibrinolytic therapy

OBJECTIVE

Treatment of posthemorrhagic ventricular dilation in premature infants is fraught with failures and complications. We have piloted a new treatment aimed at removing intraventricular blood and the cytokines associated with hydrocephalus.

METHODS

Twenty-four infants were enrolled with ventricular width enlarged to 4 mm over the 97th centile after a large intraventricular hemorrhage. Sixteen had parenchymal brain lesions before treatment. Median gestation was 28 weeks, and birth weight was 1150 g. At a median postnatal age of 17 days, 2 ventricular catheters (1 right frontal, 1 left occipital) were inserted with 13 infants also having a reservoir frontally. Tissue plasminogen activator 0.5 mg/kg was given intraventricularly 8 hours before the ventricles were irrigated with artificial cerebrospinal fluid at 20 mL/h for a median of 72 hours.

RESULTS

Seventeen of 23 survivors (74%) did not require a ventriculoperitoneal shunt. One infant (of 23 weeks' gestation) died. Two infants developed reservoir-associated infection, and 2 infants had a second intraventricular hemorrhage. Of the 19 survivors aged >12 months postterm, 8 were normal, 7 (37%) had single disability, and 4 (21%) had multiple disabilities.

CONCLUSIONS

Shunt surgery was reduced compared with historical controls with similar treatment criteria. Mortality and single and multiple disability rates all showed downward trends. Reducing pressure, free iron, and proinflammatory and profibrotic cytokines may reduce periventricular brain damage and permanent hydrocephalus. Additional advances will require a controlled trial and better knowledge of the mechanisms of hydrocephalus.

Sonographically detected subarachnoid hemorrhage: an independent predictor of neonatal posthemorrhagic hydrocephalus?

Blood from an intraventricular hemorrhage (IVH) can collect in the basilar cisterns and cause ventriculomegaly and eventual need for ventriculoperitoneal (VP) shunt. We looked for sonographic evidence of subarachnoid hemorrhage (SAH) in three basal cisterns and in the Sylvian fissure of 82 infants with IVH, 30 of whom had ventriculomegaly. We found that ultrasonographically diagnosed SAH and measurement of ventricular blood volume predict ventriculomegaly and need for VP shunt.

Transforming growth factor-beta1: a possible signal molecule for posthemorrhagic hydrocephalus?

Posthemorrhagic hydrocephalus remains a complication of preterm birth for which we lack a clear understanding and a curative therapy. Transforming growth factor beta (TGF-beta) is a cytokine that upregulates the production by fibroblasts of extracellular matrix proteins. We hypothesized that TGF-beta might be released into cerebrospinal fluid (CSF) after intraventricular hemorrhage and play a role in posthemorrhagic hydrocephalus. Total TGF-beta1 and TGF-beta2 were measured by immunoassay in CSF samples from 12 normal preterm infants, nine preterm infants with transient posthemorrhagic ventricular dilation, and 10 infants who subsequently developed permanent hydrocephalus. Five infants received intraventricular tissue plasminogen activator, and two infants were treated by drainage irrigation and fibrinolytic therapy. Median TGF-beta1 in normal CSF was 0.495 ng/mL. In infants with transient posthemorrhagic ventricular dilation, median initial CSF TGF-beta1 was 2.1 ng/mL. Infants who subsequently had permanent hydrocephalus had median initial CSF TGF-beta1, 9.7 ng/mL (differences between groups p < 0.01). Intraventricular recombinant tissue plasminogen activator was followed by a rise in CSF TGF-beta1 (p = 0.0007). Drainage irrigation and fibrinolytic therapy was followed by a fall in CSF TGF-beta1. TGF-beta2 was detected in CSF and showed similar trends, but the CSF concentration of TGF-beta1 was more than 20 times higher. These findings support the hypothesis that TGF-beta1 is released into CSF after intraventricular hemorrhage and may play an important part in hydrocephalus. The results help to explain the failure of intraventricular fibrinolytic therapy.

Posthemorrhagic hydrocephalus and brain injury in the preterm infant: dilemmas in diagnosis and management

Advances in neonatal critical care have reduced the incidence of intraventricular hemorrhage (IVH) in the newborn. Paradoxically, however, the prevalence of the complications of IVH including posthemorrhagic hydrocephalus (PHHC) has increased. By virtue of its association with long-term neurodevelopmental disability, posthemorrhagic hydrocephalus is an ominous diagnosis in the premature infant. Animal models have demonstrated that ventricular distention may cause direct cerebral parenchymal injury. Evidence for secondary parenchymal injury in the premature infant with PHHC is by necessity indirect. The precise impact of secondary parenchymal injury on the overall neurological outcome of premature infants with PHHC remains unclear in large part because of the vulnerability of the immature brain to other forms of injury (e.g., periventricular leukomalacia) that may be difficult to distinguish from injury due to distention. Furthermore, parenchymal injury due to PVL may cause ventricular enlargement that does not benefit from CSF diversion. Because these primary and secondary mechanisms of injury may operate concurrently, the precise or dominant cause of ventricular enlargement is often difficult to establish with certainty in the neonatal period. These diagnostic dilemmas have in turn impeded the development and evaluation of therapies specifically aimed at reversing ventricular distention and preventing secondary parenchymal injury. This article focuses on the current dilemmas in diagnosis and management of this potentially reversible form of injury as well as on potential future strategies for its prevention.

CNS fibrinolysis: a review of the literature with a pediatric emphasis

In vitro studies of cerebrospinal fluid indicate that normal cerebrospinal fluid contains very low levels of fibrinolytic enzymes but that fibrinolytic activity is higher in pathologic compared with normal conditions and in older compared with younger patients. Because of the low endogenous fibrinolytic activity of the central nervous system, intraventricular fibrinolytic therapy has been studied in adult and pediatric patients for the treatment of intraventricular hemorrhage/posthemorrhagic hydrocephalus and subarachnoid hemorrhage with secondary cerebral vasospasm. A review of the literature about endogenous and exogenous fibrinolysis studies of animals, adult humans, and pediatric humans reveals a record of predominant safety and efficacy. Although its use in the adult population for the treatment of subarachnoid hemorrhage with secondary vasospasm has become an accepted therapy in some centers, its use in the pediatric population is less common. It is no longer considered in the treatment of meningitis, but its role in the treatment of intraventricular hemorrhage/posthemorrhagic hydrocephalus is still being investigated.

Intraventricular urokinase for the treatment of posthemorrhagic hydrocephalus

This case series pilot study assessed the safety of intraventricular urokinase administration, alternating with cerebrospinal fluid (CSF) drainage. A secondary objective was to comment on whether this therapy achieves fibrinolysis, and whether this fibrinolysis is sufficient to prevent progression of hydrocephalus to requirement for ventriculoperitoneal shunt. Six preterm infants with progressive posthemorrhagic hydrocephalus requiring treatment with a ventricular drain received an infusion of intraventricular urokinase alternating with CSF drainage for 3 days. Of the 6 treated patients, the median gestation at birth was 26.5 weeks and the median age at treatment was 30 days. One patient had an elevation in CSF erythrocyte count most likely due to successful clot lysis. One patient had an elevated CSF leukocyte count consistent with transient meningeal irritation. No other side effects were noted. Fibrinolysis was achieved in the CSF, as documented by markedly elevated D-dimer levels. Clot size diminished ultrasonographically. However, all 6 patients eventually required a ventriculoperitoneal shunt. We conclude that intermittent infusion of intraventricular urokinase alternating with periods of CSF drainage is probably a safe way to achieve a fibrinolytic state. However, when administered at the relatively late point in the neonatal course when a ventricular drain is required, this fibrinolytic state is not sufficient to decrease the requirement for ventriculoperitoneal shunt.

Thrombolytic therapy in neurointensive care

Thrombolytic therapy has been studied in acute ischemic stroke, intracranial hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, and sagittal sinus thrombosis. This form of therapy has an evolving role in contemporary neurologic practice, and increased investigational fervor will ensure more exacting therapeutic alternatives for stroke victims in the future.

Glial reaction in periventricular areas of the brainstem in fetal and neonatal posthemorrhagic hydrocephalus and congenital hydrocephalus

This immunohistochemical, neuropathological study was performed on the ventricular wall of the brainstem in children with fetal and neonatal posthemorrhagic and congenital hydrocephalus. In posthemorrhagic hydrocephalus (PHH), hemosiderin deposits, nodular gliosis, ependymal cell loss and subependymal rosette formation developed subventricularly after 2 weeks of age. Ferritin-positive reactive microglia were well stained until about 2 weeks of age and thereafter diminished as reactive astrocytosis occurred. In congenital hydrocephalus (CH), the damage to the ventricular wall was less than in PHH at all ages and was associated with only mild astrogliosis. These differences in the neuropathological findings of periventricular regions, consisting mainly of glial reactions between PHH and CH, are due to differences in pathophysiology, and the timing of the insult in both conditions. The differences may be due to the effects of intraventricular hemorrhage and/or rapidly increased intracranial pressure in PHH. These results may have implications for the neurological prognosis in children with PHH.

Neonatal posthemorrhagic hydrocephalus: neuropathologic and immunohistochemical studies

A neuropathologic study was undertaken to examine associated brain damage in patients with fetal and neonatal posthemorrhagic hydrocephalus (PHH). In PHH the association of periventricular leukomalacia and pontosubicular necrosis was not increased, but that of cerebellar subarachnoid hemorrhage and olivo-cerebellar pathology was significantly increased. All patients with the olivocerebellar pathology exhibited associated cerebellar subarachnoid hemorrhage and loss of Purkinje cells. Ferritin-positive glia were increased in the molecular layer of most patients, and glial fibrillary acidic protein-positive glia and/or fibers were increased in the molecular layer, granular layer, and white matter in older infants. Neonates with PHH had more severe brain lesions than those with only intraventricular hemorrhage. At 2 weeks of age in PHH, the ventricular wall displayed hemosiderin deposits and nodular gliosis, with ependymal cell loss and subependymal rosette formation. These findings may be closely related to the underlying pathogenesis and neurologic sequelae of PHH.

Low levels of plasminogen in cerebrospinal fluid after intraventricular haemorrhage: a limiting factor for clot lysis?

The aim of this study was to measure plasminogen in the cerebrospinal fluid (CSF) of control neonates with no infection or haemorrhage and in infants who had suffered intraventricular haemorrhage (IVH). A chromogenic substrate method was used. The 16 reference infants had a median CSF plasminogen level of 0.74% of that of normal adult plasma (range 0.17-1.1%). The 11 infants with IVH had a median CSF plasminogen level of 0.55% of normal adult plasma (range 0-4.4%). Six of the IVH infants went on to develop permanent hydrocephalus despite the use of intraventricular plasminogen activators. Endogenous fibrinolysis and the potential for fibrinolytic treatment in the CSF may be limited by low concentrations of plasminogen, and administration of recombinant plasminogen may assist attempts to clear intraventricular blood clots.