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Noiphithak R, Phumichard T, Ratanavinitkul W, Rukskul P. Prediction of Permanent Shunt Dependency in Patients with Intraventricular Hemorrhage: Outcomes of Early External Ventricular Drainage Weaning Protocol. World Neurosurg 2023; 179:e575-e581. [PMID: 37689359 DOI: 10.1016/j.wneu.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/02/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Hydrocephalus remains a common sequela of intraventricular hemorrhage (IVH) despite adequate drainage of the hematoma, including endoscopic surgery, intraventricular fibrinolysis, and external ventricular drainage (EVD). Moreover, the appropriate timing for conversion from EVD to ventriculoperitoneal shunt (VPS) is uncertain. This study aimed to evaluate the predictors of shunt dependency in patients with IVH based on the early EVD weaning protocol in our institution. METHODS We retrospectively reviewed medical records of patients who were diagnosed with primary IVH and secondary IVH from spontaneous intracerebral hemorrhage during the period 2018-2021. Predictors associated with shunt dependency were identified using a logistic regression model. The cutoff point of each variable was selected by receiver operating characteristic curve analysis. Furthermore, shunt complications were reported as a safety measure of our early EVD weaning protocol. RESULTS The analysis included 106 patients. After IVH treatment, 15 (14%) patients required ventriculoperitoneal shunt, whereas 91 (86%) patients were shunt-free. The diameter of posttreatment temporal horn and the degree of IVH reduction were the significant predictors of shunt dependency. Moreover, patients with IVH reduction of >45% and temporal horn diameter of <9 mm had a lower probability of shunt dependency. Shunt failure was found in 2 (13.3%) patients. CONCLUSIONS This study showed that a large temporal horn diameter and a lower degree of IVH removal were predictors of shunt dependency in patients with IVH. In addition, early conversion from EVD to ventriculoperitoneal shunt is safe and feasible.
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Affiliation(s)
- Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Klongluang, Pathumthani, Thailand.
| | - Thapakorn Phumichard
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Klongluang, Pathumthani, Thailand
| | - Warot Ratanavinitkul
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Klongluang, Pathumthani, Thailand
| | - Pataravit Rukskul
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Klongluang, Pathumthani, Thailand
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Li CR, Yang MY, Cheng WY, Tseng HC, Lin YY, Liu YH, Shen CC, Yen CM. Urokinase administration for intraventricular hemorrhage in adults: A retrospective analysis of hemorrhage volume reduction and clinical outcomes. J Chin Med Assoc 2023; 86:930-934. [PMID: 37528523 DOI: 10.1097/jcma.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) is a type of ventricular bleeding that results in significant morbidity and mortality. Multiple studies have investigated the use of urokinase in IVH treatment. The use of urokinase may lead to higher rates of hematoma resolution and lower mortality rates. However, further studies are required to determine efficacy of urokinase administration. This study examined the association between urokinase use, IVH volume reduction, and clinical outcomes. METHODS In total, 94 adult patients with hypertensive intracerebral hemorrhage with ventricular extension or primary IVH were enrolled between 2015 and 2021. Participants were categorized into two groups: "EVD combined with fibrinolysis" and "EVD only." The primary objective was to assess the reduction of IVH severity. Additionally, the study evaluated the functional outcomes and shunt dependency rate as secondary outcomes. Non-contrast computed tomography scans were obtained to measure the severity of IVH using the mGRAEB score. The main outcomes were the association among urokinase administration, reduced IVH severity, and functional outcomes. RESULTS There were no significant differences in the reduction rate of mGRAEB scores within a 7-day period (-50.0 [-64.4 to -32.5] % vs -44.2 [-59.3 to -7.9] %; p = 0.489). In addition, investigation of the third and fourth ventricles showed similar findings between the two groups. Urokinase treatment was not associated with significant differences in the modified Rankin Scale (5.0 (4.0-5.0) vs. 4.5 (4.0-5.0), p = 0.674) or shunt dependency rate (33.3% vs 39.3%, p = 0.58). CONCLUSION This study found that intraventricular urokinase use in patients with IVH was not associated with reduced IVH severity. In addition, urokinase use was not associated with better functional outcomes or minor shunt dependency rates.
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Affiliation(s)
- Chi-Ruei Li
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Meng-Yin Yang
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Oncology Neurosurgery Division, Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- College of Nursing, Central Taiwan University of Science and Technology, Taichung, Taiwan, ROC
| | - Wen-Yu Cheng
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan, ROC
- Department of Physical Therapy, Hung Kuang University, Taichung, Taiwan, ROC
| | - Huan-Chin Tseng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Ying Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yu-Hao Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chiung-Chyi Shen
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Physical Therapy, Hung Kuang University, Taichung, Taiwan, ROC
- Basic Medical Education, Central Taiwan University of Science and Technology, Taichung, Taiwan, ROC
| | - Chun-Ming Yen
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
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Zhang L, Mu Z, Shen G, Yang M. The accuracy and safety of intraoperative ultrasound-guided external ventricular drainage in intraventricular hemorrhage. Sci Rep 2023; 13:11525. [PMID: 37460575 DOI: 10.1038/s41598-023-38567-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
Severe IVH often results in a poor outcome. Currently, EVD is a standard treatment for IVH, but there is little research to show whether using ultrasound to guide the catheter placement improves outcome. Patients with severe IVH who had iUS-guided EVD (the iUS-guided group) were enrolled retrospectively and compared with a group who had EVD performed without ultrasound guidance (the control group) from January 2016 to July 2022. Data were collected on accuracy of the catheter placement, complications and outcome at 3 months assessed by mRS. The accuracy of the EVD placement was classified as optimal placement, sub-optimal placement and misplacement according to the position of the catheter tip. The complications reported are catheter-related hemorrhage, intracranial infection and hydrocephalus. There were 105 cases enrolled, with 72 patients in the iUS-guided group having 131 catheters inserted and 33 patients in the group where ultrasound was not used with a total of 59 catheters. 116 (88.55%) were optimally placed, 12 (9.16%) sub-optimal and 3 (2.29%) misplaced in the iUS-guided group, while 25 (42.37%) were in optimally placed, 30 (50.85%) sub-optimal and 4(6.78%) misplaced in the control group. Accuracy of placement was highly significantly improved using ultrasound (P < 0.001). The operation time and the average catheterized time were longer in the iUS-guided group (P < 0.05), but the complication rates were no different between the groups. The mRS at three months was not significantly different between the two groups. Using iUS to place EVD catheters in patients with severe IVH is a safe technique delivering more accurate catheter placement without increasing the complication rate compared with freehand placement.
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Affiliation(s)
- Lijun Zhang
- Department of Neurosurgery, Taizhou First People's Hospital, Taizhou, Zhejiang, 318020, People's Republic of China.
- Department of Neurosurgery, Wenzhou Medical University Affiliated Huangyan Hospital, Taizhou, Zhejiang, 318020, People's Republic of China.
| | - Zhaohui Mu
- Department of Neurosurgery, Taizhou First People's Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
- Department of Neurosurgery, Wenzhou Medical University Affiliated Huangyan Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
| | - Guoliang Shen
- Department of Neurosurgery, Taizhou First People's Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
- Department of Neurosurgery, Wenzhou Medical University Affiliated Huangyan Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
| | - Ming Yang
- Department of Neurosurgery, Taizhou First People's Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
- Department of Neurosurgery, Wenzhou Medical University Affiliated Huangyan Hospital, Taizhou, Zhejiang, 318020, People's Republic of China
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Haldrup M, Miscov R, Mohamad N, Rasmussen M, Dyrskog S, Simonsen CZ, Grønhøj M, Poulsen FR, Bjarkam CR, Debrabant B, Korshøj AR. Treatment of Intraventricular Hemorrhage with External Ventricular Drainage and Fibrinolysis: A Comprehensive Systematic Review and Meta-Analysis of Complications and Outcome. World Neurosurg 2023; 174:183-196.e6. [PMID: 36642373 DOI: 10.1016/j.wneu.2023.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND External ventricular drainage (EVD) is a key factor in the treatment of intraventricular hemorrhage (IVH) but associated with risks and complications. Intraventricular fibrinolysis (IVF) has been proposed to improve clinical outcome and reduce complications of EVD treatment. The following review and metaanalysis provides a comprehensive evaluation of IVH treatment with external ventricular drainage (EVD) and intraventricular fibrinolysis (IVF) with regards to complications and clinical outcomes. METHODS The PRISMA guidelines were followed preparing this review. Studies included in the meta-analysis were compared using forest plots and the related odds ratios. RESULTS After a literature search, 980 articles were identified and 65 and underwent full-text review. Forty-two articles were included in the review and meta-analysis. We found that bolted and antibiotic-coated catheters were superior to tunnelled/uncoated catheters (P < 0.001) and antibiotic- vs. silver-impregnated catheters (P < 0.001]) in preventing infection. Shunt dependency was related to the volume of blood in the ventricles but unaffected by IVF (P = 0.98). IVF promoted hematoma clearance, decreased mortality (22.4% vs. 40.9% with IVF vs. no IVF, respectively, P < 0.00001), improved good functional outcomes (47.2% [IVF] vs. 38.3% [no IVF], P = 0.03), and reduced the rate of catheter occlusion from 37.3% without IVF to 10.6% with IVF (P = 0.0003). CONCLUSIONS We present evidence and best practice recommendations for the treatment of IVH with EVD and intraventricular fibrinolysis. Our analysis further provides a comprehensive quantitative reference of the most relevant clinical endpoints for future studies on novel IVH technologies and treatments.
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Affiliation(s)
- Mette Haldrup
- Department of Neurosurgery, Aarhus University Hospital, Aarhus N, Denmark.
| | - Rares Miscov
- Department of Neurosurgery, Aalborg University Hospital, Aalborg, Denmark
| | - Niwar Mohamad
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Mads Rasmussen
- Department of Anesthesiology, Section of Neuroanesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Stig Dyrskog
- Department of Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Mads Grønhøj
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | | | - Birgit Debrabant
- Department of Mathematics and Computer Science, Data Science and Statistics, University of Southern Denmark, Odense M, Denmark
| | - Anders Rosendal Korshøj
- Department of Neurosurgery, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Chen A, Li J, Luo H, Sun T, Zhou R, Xiang R, Tong Z. Does preventive external ventricular drainage benefit patients with mild ventricular hemorrhage? Neurosurg Rev 2023; 46:84. [PMID: 37055679 DOI: 10.1007/s10143-023-01994-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 04/15/2023]
Abstract
External ventricular drainage (EVD) is the routine intraventricular hemorrhage (IVH) treatment. Neurological deterioration and symptomatic hydrocephalus are often the default indications for EVD insertion. However, the outcome of preventive EVD is unclear in patients with mild IVH. This study aimed to determine whether EVD is beneficial in patients with mild IVH. This study aimed to determine whether EVD is beneficial in patients with mild IVH. Data from IVH patients treated conservatively or with EVD at two hospitals from January 2017 to December 2022 were analyzed retrospectively. Patients with a Glasgow Coma Scale (GCS) score of 12-14 and a modified Graeb score (mGS) ≥ 5 at admission were included. The primary outcome was poor functional status, defined as a modified Rankin Scale (mRS) score of 3-6 at 90 days. Secondary outcomes included the distribution of mRS score categories, the resolution time of intraventricular blood clots, and complications. Forty-nine patients were enrolled in the study: 21 patients in the EVD group, 28 in the non-EVD group, and 13 in the EVD group who received urokinase injections. ICH volume was an independent predictor of poor functional status. Currently, no evidence supports that preventive EVD benefits patients with mild IVH.
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Affiliation(s)
- Ao Chen
- Department of Neurosurgery, YueYang People's Hospital, Yueyang, Hunan, China.
| | - JianXian Li
- Department of Neurosurgery, YueYang People's Hospital, Yueyang, Hunan, China
| | - Hao Luo
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Tao Sun
- Department of Neurosurgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - RenHui Zhou
- Department of Neurosurgery, YueYang People's Hospital, Yueyang, Hunan, China
| | - Rong Xiang
- Department of Neurosurgery, YueYang People's Hospital, Yueyang, Hunan, China
| | - ZhongChi Tong
- Department of Neurosurgery, YueYang People's Hospital, Yueyang, Hunan, China
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Yan Z, Wan X, Li Y, Zhao K, Huang Y, He X, Zhang X, Ma X, Liu Y, Niu H, Shu K, Zhang H, Lei T. Safety and efficacy of extra-ventricular drainage combined with urokinase administration in the management of intraventricular hemorrhage. Neurochirurgie 2022; 68:e53-e59. [DOI: 10.1016/j.neuchi.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 11/26/2022]
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Abstract
Intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) carry a very dismal prognosis. Several medical and surgical attempts have been made to reduce mortality and to improve neurological outcomes in survivors. Aggressive surgical treatment of ICH through craniotomy and microsurgical evacuation did not prove to be beneficial to these patients, compared to the best medical treatment. Similarly, the conventional treatment of IVH using an EVD is often effective in controlling ICP only initially, as it is very likely for the EVD to become obstructed by blood clots, requiring frequent replacements with a consequent increase of infection rates.Minimally invasive techniques have been proposed to manage these cases. Some are based on fibrinolytic agents that are infused in the hemorrhagic site through catheters with a single burr hole. Others are possible thanks to the development of neuroendoscopy. Endoscopic removal of ICH through a mini-craniotomy or a single burr hole, and via a parafascicular white matter trajectory, proved to reduce mortality in this population, and further randomized trials are expected to show whether also a better neurological outcome can be obtained in survivors. Moreover, endoscopy offers the opportunity to access the ventricular system to aspirate blood clots in patients with IVH. In such cases, the restoration of patency of the entire CSF pathway has the potential to improve outcome and reduce complications and now it is believed to decrease shunt-dependency.
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Affiliation(s)
- Alberto Feletti
- Department of Neurosciences, Biomedicine, and Movement Sciences, Institute of Neurosurgery, University of Verona, Verona, Italy.
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Covrig RC, Schellinger PD, Glahn J, Alomari A, Schmieder K, Wiese M, Knappe UJ. Shunt Dependence after Intraventricular Hemorrhage and Intraventricular Fibrinolysis with uPA versus rt-PA. J Neurol Surg A Cent Eur Neurosurg 2022; 84:255-260. [PMID: 35100632 DOI: 10.1055/s-0041-1741546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND We compare the effect of urokinase (urokinase-type plasminogen activator [uPA]) versus alteplase (recombinant tissue plasminogen activator [rt-PA]) for intraventricular fibrinolysis (IVF) in patients with intraventricular hemorrhage (IVH) on ventriculoperitoneal shunt (VPS) dependence, functional outcome, and complications in the management of IVH. METHODS We retrospectively reviewed the patients admitted with IVH or intracerebral hemorrhage (ICH) with IVH within 7 years in three different departments and found 102 patients who met the inclusion criteria. The primary end points were VPS dependence and Glasgow outcome score (GOS) at 3 months. Secondary end points were rate of rebleeding under IVF and incidence of treatment-related complications. Patients were divided into three groups: group I comprised patients treated with external ventricular drain (EVD) and IVF with uPA; group II comprised patients treated with EVD and IVF with rt-PA; and group III comprised patients treated with EVD alone. RESULTS In all, 9.8% patients needed VPS: 12.2% in group I and 15.0% in group II, with no statistically significant difference. VPS patients had higher values of the modified Graeb score (mGS), IVH score, and IVH volume. We saw a trend for a better outcome in group II, with six patients achieving a GOS of 4 or 5 after 3 months. The mortality rate was higher in groups I and III. We found no statistical difference in the complication rate between groups I and II. Logistic regression analysis revealed that higher mGS and age predicted worse prognosis concerning mortality. The risk for death rose by 7.8% for each year of age. Any additional mGS point increased the chances of death by 9.7%. CONCLUSION Our data suggest that both uPA and rt-PA are safe and comparable regarding incidence of communicating hydrocephalus, and age and mGS are predictive for mortality.
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Affiliation(s)
- Raul-Ciprian Covrig
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Peter D Schellinger
- Department of Neurology, Johannes Wesling Hospital Minden, Minden, Nordrhein-Westfalen, Germany
| | - Joerg Glahn
- Department of Neurology, Johannes Wesling Hospital Minden, Minden, Nordrhein-Westfalen, Germany
| | - Ali Alomari
- Department of Neurosurgery, Johannes Wesling Hospital Minden, Minden, Germany
| | - Kirsten Schmieder
- Department of Neurosurgery, Knappschafts-Krankenhaus Bochum Langendreer, Bochum, Germany
| | - M Wiese
- Department of Neurosurgery, Knappschafts-Krankenhaus Bochum Langendreer, Bochum, Germany
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Polster SP, Carrión-Penagos J, Awad IA. Management of Intraventricular Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00073-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Pai A, Hegde A, Nair R, Menon G. Adult Primary Intraventricular Hemorrhage: Clinical Characteristics and Outcomes. J Neurosci Rural Pract 2020; 11:623-628. [PMID: 33144801 PMCID: PMC7595788 DOI: 10.1055/s-0040-1716770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background
Adult primary intraventricular hemorrhage (PIVH) is a rare type of hemorrhagic stroke that is poorly understood. The study attempts to define the clinical profile, yield of diagnostic cerebral angiography, and prognosis of patients with PIVH.
Patients and Methods
Retrospective data analysis of all patients with PIVH admitted between February 2015 and February 2019 at a tertiary care center. Outcome was assessed using the modified Rankin scale (mRS) at 6 months.
Results and Discussion
Our study group of 30 patients constituted 3.3% (30/905) of our spontaneous intracerebral hemorrhage (SICH) patients in the study period. The mean Glasgow Coma Score on admission was 11 ± 3.33 and the mean IVH Graeb score was 5.2±2.4. All patients underwent angiography. Angiography detected moyamoya disease in four patients (13.3%) and aneurysms in two patients (6.6%) and these patients were managed surgically. Extraventricular drainage with intraventricular instillation of Streptokinase was performed in five patients. The rest of the patients was managed conservatively. At 6-month follow-up, 25 patients (83.33%) achieved favorable outcome (mRS score of 0.1 or 2), whereas five (16.66%) patients had a poor outcome (mRS score of 3 or more. Three patients succumbed to the illness. IVH Graeb score and presence of hydrocephalus have significant correlation with poor outcome.
Conclusion
PIVH is an uncommon entity but carries a better long-term prognosis than SICH angiography helps in diagnosing surgically remediable underlying vascular anomalies and is indicated in all cases of PIVH.
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Affiliation(s)
- Aswin Pai
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ajay Hegde
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Rajesh Nair
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Prediction Models for Recurrence of Chronic Subdural Hematoma in Patients Underwent Twist-Drill Craniostomy Combined With Urokinase Instillation. J Craniofac Surg 2020; 31:2267-2272. [PMID: 33136868 DOI: 10.1097/scs.0000000000006779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The recurrence of chronic subdural hematoma (CSDH) is high post-treatment. In this study, we aimed to construct individualized models for prediction of the postoperative recurrence of CSDH in patients underwent twist-drill craniostomy combined with urokinase (UK) instillation. In total, 183 patients with CSDH were retrospectively enrolled. In summary, 21 candidate factors were retrieved from past medical records. The least absolute shrinkage and selection operator regression was adopted to reduce the high dimensionality of data. Four predictors: preoperative hematoma volume, encephalatrophy, brain re-expansion, and UK instillation frequency were filtered from the 21 candidate factors using the least absolute shrinkage and selection operator method. Binary logistic regression model was employed to establish preoperative and postoperative prediction models. The preoperative model included preoperative hematoma volume and encephalatrophy whereas the postoperative model included brain re-expansion and UK instillation frequency. The predictive performance of the nomograms was evaluated by the receiver operating characteristic curve and calibration chart. Area under curve of the preoperative and postoperative models were 0.755 (95% confidence interval: 0.690-0.889) and 0.782 (95% confidence interval: 0.720-0.936), respectively, indicating good discrimination ability. The calibration results showed good fitting between the predicted probability and the actual probability. Finally, a decision curve analysis revealed excellent clinical performance of the proposed nomograms. Functionally, the preoperative model was used to identify high-risk patients with CSDH and application of UK, while the postoperative model was applied to guide physician-patients communication during follow-up. These 2 prediction models provide a basis for further clinical and experimental studies.
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Li M, Mu F, Han Q, Su D, Guo Z, Chen T. Intraventricular fibrinolytic for the treatment of intraventricular hemorrhage: a network meta-analysis. Brain Inj 2020; 34:864-870. [PMID: 32447964 DOI: 10.1080/02699052.2020.1764103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To explore which intraventricular fibrinolytic agent - urokinase (UK) or recombinant tissue plasminogen activator (rt-PA) - combined with extraventricular drainage (EVD) is most suitable for patients with spontaneous intraventricular hemorrhage (IVH). PATIENTS AND METHODS We searched PubMed, MEDLINE, OVID, Embase, and Cochrane Library databases for relevant articles and assessed their quality and extracted statistical analyses using Stata 13.0 and Revman 5.3 software. RESULTS Compared with EVD alone, EVD combined with an agent causing intraventricular fibrinolysis (IVF) improved the survival and prognosis of patients with IVH. Regarding the patients' survival rates and prognoses, the treatments, from best to worst results were EVD + UK, EVD + rt-PA, EVD alone. The proportion of patients with serious disability also increased with these treatments, however, with the highest to lowest proportions being EVD + rt-PA, EVD + UK, EVD alone. In addition, EVD + IVF was associated with a higher risk of intracranial rebleeding (from lowest to highest incidence: EVD alone, EVD + rt-PA, EVD + UK). Finally, EVD + UK is associated with an increased risk of potential intracranial infection (from lowest to highest incidence: EVD + rt-PA, EVD alone, EVD + UK). CONCLUSIONS EVD + UK may be the best approach to improving patients' survival rate and prognosis. However, it also presents the highest risk of intracranial infection and rebleeding. EVD + IVF increased the proportion of patients with serious disability.
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Affiliation(s)
- Mei Li
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
| | - Fengqun Mu
- Department of Neurology, Gongren Hospital , Tangshan, Hebei Province, China
| | - Qian Han
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
| | - Dongpo Su
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
| | - Zhenzhong Guo
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
| | - Tong Chen
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital , Tangshan, Hebei Province, China
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Vagal V, Venema SU, Behymer TP, Mistry EA, Sekar P, Sawyer RP, Gilkerson L, Moomaw CJ, Haverbusch M, Coleman ER, Flaherty ML, Van Sanford C, Stanton RJ, Anderson C, Rosand J, Woo D. White Matter Lesion Severity is Associated with Intraventricular Hemorrhage in Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104661. [PMID: 32122778 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/15/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location. METHODS Utilizing the patient population from 2 large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates. RESULTS Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (P < .0001). Multivariable analysis demonstrated that moderate-severe WML, deep ICH, and increasing ICH volume were independently associated with presence of IVH. We found an increased risk of IVH with moderate-severe WML (OR = 1.38; 95%Cl 1.03-1.86, P = .0328) in the subset of lobar hemorrhages. CONCLUSIONS Moderate to severe WML is a risk for IVH. Even in lobar ICH hemorrhages, severe WML leads to an independent increased risk for ventricular rupture.
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Affiliation(s)
- Vaibhav Vagal
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio.
| | - Simone U Venema
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Tyler P Behymer
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Eva A Mistry
- Vanderbilt University Medical Center, Department of Neurology, Nashville, Tennessee
| | - Padmini Sekar
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Russell P Sawyer
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Lee Gilkerson
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Charles J Moomaw
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Mary Haverbusch
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | | | | | | | - Robert J Stanton
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | | | - Jonathan Rosand
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Daniel Woo
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
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14
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van Solinge TS, Muskens IS, Kavouridis VK, Gormley WB, Mekary RA, Broekman MLD, Arnaout O. Fibrinolytics and Intraventricular Hemorrhage: A Systematic Review and Meta-analysis. Neurocrit Care 2020; 32:262-271. [PMID: 31376141 PMCID: PMC7012971 DOI: 10.1007/s12028-019-00786-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Intraventricular hemorrhage (IVH) is an independent poor prognostic factor in subarachnoid and intra-parenchymal hemorrhage. The use of intraventricular fibrinolytics (IVF) has long been debated, and its exact effects on outcomes are unknown. A systematic review and meta-analysis were performed in accordance with the PRISMA guidelines to assess the impact of IVF after non-traumatic IVH on mortality, functional outcome, intracranial bleeding, ventriculitis, time until clearance of third and fourth ventricles, obstruction of external ventricular drains (EVD), and shunt dependency. Nineteen studies were included in the meta-analysis, totaling 1020 patients. IVF was associated with lower mortality (relative risk [RR] 0.58; 95% confidence interval [CI] 0.47-0.72), fewer EVD obstructions (RR 0.41; 95% CI 0.22-0.74), and a shorter time until clearance of the ventricles (median difference [MD] - 4.05 days; 95% CI - 5.52 to - 2.57). There was no difference in good functional outcome, RR 1.41 (95% CI 0.98-2.03), or shunt dependency, RR 0.93 (95% CI 0.70-1.22). Correction for publication bias predicted an increased risk of intracranial bleeding, RR 1.67 (95% CI 1.01-2.74) and a lower risk of ventriculitis, RR 0.68 (95% CI 0.45-1.03) in IVH patients treated with IVF. IVF was associated with improved survival, faster clearance of blood from the ventricles and fewer drain obstructions, but further research is warranted to elucidate the effects on ventriculitis, long-term functional outcomes, and re-hemorrhage.
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Affiliation(s)
- Thomas S van Solinge
- Computational Neurosciences Outcome Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Ivo S Muskens
- Computational Neurosciences Outcome Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Vasileios K Kavouridis
- Computational Neurosciences Outcome Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - William B Gormley
- Computational Neurosciences Outcome Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Computational Neurosciences Outcome Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, MA, USA
| | - Marike L D Broekman
- Computational Neurosciences Outcome Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Omar Arnaout
- Computational Neurosciences Outcome Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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15
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Mei L, Fengqun M, Qian H, Dongpo S, Zhenzhong G, Tong C. Exploration of Efficacy and Safety of Interventions for Intraventricular Hemorrhage: A Network Meta-Analysis. World Neurosurg 2019; 136:382-389.e6. [PMID: 31698131 DOI: 10.1016/j.wneu.2019.10.177] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/26/2019] [Accepted: 10/28/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To explore whether endoscopy surgery (ES) and extraventricular drainage (EVD) combined with intraventricular fibrinolytic (IVF) are superior to EVD alone in patients with intraventricular hemorrhage (IVH) and to determine which procedure is more suitable in such patients. METHODS We searched the following databases: PubMed, MEDLINE, Ovid, Embase, and Cochrane Library. Randomized controlled trials and nonrandomized studies comparing ≥2 different interventions in patients with IVH were included. The quality of the included studies was assessed. Pairwise and network meta-analysis were performed using software Stata 13.0 and Revman 5.3. RESULTS Compared with the EVD-alone intervention, the ES regimen, EVD combined with urokinase (UK), and EVD combined with recombinant tissue plasminogen activator (rt-PA) regimens all resulted in better survival and prognosis in patients with IVH. For both survival rate and prognosis, the order from best to worst was ES, EVD combined with UK, EVD combined with rt-PA, and EVD-alone. However, EVD combined with IVF had a high risk of intracranial rebleeding; the order of intracranial rebleeding risk from lowest to highest was ES, EVD-alone, EVD combined with rt-PA, and EVD combined with UK. The risk of intracranial infection in EVD combined with rt-PA was lower than that of EVD-alone, but EVD combined with UK also had a higher risk than did EVD-alone. The risk of intracranial infection from lowest to the highest was ES, EVD combined with rt-PA, EVD-alone, and EVD combined with UK. CONCLUSIONS Our analysis showed that ES is more suitable for patients with IVH. ES not only improved the survival and prognosis but also had the lowest risk of ventriculoperitoneal shunt and intracranial rebleeding or infection.
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Affiliation(s)
- Li Mei
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China
| | - Mu Fengqun
- Department of Neurology, Gongren Hospital, Tangshan, Hebei Province, China
| | - Han Qian
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China
| | - Su Dongpo
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China
| | - Guo Zhenzhong
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China
| | - Chen Tong
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei Province, China.
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16
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Krel M, Brazdzionis J, Podkovik S, Miulli DE, Wacker MR, Beamer Y. Safety and Efficacy of Transcatheter Administration of Tissue Plasminogen Activating Factor as Adjuvant Therapy for Intraventricular Hemorrhage. Cureus 2019; 11:e5785. [PMID: 31723544 PMCID: PMC6825502 DOI: 10.7759/cureus.5785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective Stroke is the fifth leading cause of death in the United States and the leading cause of disability. Hemorrhagic stroke has higher risks of mortality and neurologic deficit. Higher still, acute intraventricular hemorrhage (IVH) has mortality between 50% and 80% while complicating subarachnoid hemorrhage in 15% of cases and intracerebral hemorrhage in 40% of cases. We sought to demonstrate that early adjuvant intraventricular recombinant tissue plasminogen activating factor (rt-PA) improved outcomes. Methods Retrospective chart review was performed on patients aged 18-95 years with external ventricular drain (EVD) and intraventricular rt-PA for clot evacuation in IVH between 2005 and 2015. In total, 22 patients met the inclusion criteria. Generalized linear modeling was performed with factorial analysis using the Glasgow Coma Score (GCS) on arrival, GCS at EVD placement, EVD day of onset of rt-PA administration, GCS at onset of rt-PA administration, total duration of EVD, necessity of ventriculoperitoneal (VP) shunt, occurrence of ventriculitis, day of ventriculitis, GCS after rt-PA, length of stay (LOS) in the intensive care unit (ICU), and hospital disposition. Results Presenting GCS affected LOS significantly. Ventriculitis only significantly affected ICU LOS. GCS after rt-PA only significantly affected discharge GCS. EVD day of rt-PA protocol commencement demonstrated significant effects on EVD duration and cerebrospinal fluid (CSF) diversion requirement. Age affected ICU and hospital LOS. Conclusion These findings argue for larger prospective trials of EVD day two rt-PA protocol inception in acute IVH. Reported ventriculitis rates with EVDs are 8.8%, while we demonstrated a rate of 18% without significant effects except in ICU LOS. Transcatheter intraventricular rt-PA is safe and effective as an adjuvant in acute spontaneous intraventricular hemorrhage with the greatest benefit of rt-PA protocol at EVD day two.
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Affiliation(s)
- Mark Krel
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Stacey Podkovik
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | | | - Yancey Beamer
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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17
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Du B, Shan AJ, Peng YP, Wang J, Peng KW, Zhong XL, Zhang Y. A new modified neuroendoscope technology to remove severe intraventricular haematoma. Brain Inj 2018; 32:1142-1148. [PMID: 29889578 DOI: 10.1080/02699052.2018.1469042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Minimally invasive endoscopic haematoma evacuation is widely used in the treatment of intraventricular haemorrhage. However, its technique still has room for improvement. A new modified neuroendoscope technology (MNT) was used in this study and we explored its safety and efficacy in the treatment of severe acute intraventricular haemorrhage by comparing it with extraventricular drainage plus urokinase thrombolytic (EVD + UT) therapy. METHODS The following parameters were compared between the MNT group and the control group: incision design, operation time, ICU monitoring time, ventricular drainage tube (VDT) placement time, post-operative drainage tube obstruction (PDTO) rate, post-operative complications rate, 6-month mortality and Glasgow Outcome Scale (GOS). RESULTS A total of 85 patients were enrolled. The ICU monitoring times, VDT placement times, PDTO rate were shorter in the MNT group. Multivariable logistic regression identified that good medium-term outcome (GOS scores 4-5) was significantly associated with MNT applied (OR 1.017, 95% CI 1.005-1.029, p = 0.008), age under 65 years (OR 4.223, 95% CI, 1.322-17.109, p = 0.034) and pre-operation GCS scores more than 10 (OR 3.427, 95% CI 1.048-11.205, p = 0.040). CONCLUSION MNT surgery for severe intraventricular haematoma evacuation is a safe and efficient new surgical option. This technique is minimally invasive and may be helpful to provide good outcomes for selected patients.
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Affiliation(s)
- Bo Du
- a Department of Emergency , Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University , Shenzhen , China
| | - Ai-Jun Shan
- a Department of Emergency , Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University , Shenzhen , China
| | - Yu-Ping Peng
- b Department of Neurosurgery , Nanfang Hospital, Southern Medical University , Guangzhou , China
| | - Jin Wang
- a Department of Emergency , Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University , Shenzhen , China
| | - Kai-Wen Peng
- b Department of Neurosurgery , Nanfang Hospital, Southern Medical University , Guangzhou , China
| | - Xian-Liang Zhong
- a Department of Emergency , Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University , Shenzhen , China
| | - Yujuan Zhang
- c Department of Ultrasound , Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University , Shenzhen , China
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18
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Du B, Shan AJ, Zhang YJ, Wang J, Peng KW, Zhong XL, Peng YP. The intra-neuroendoscopic technique: A new method for rapid removal of acute severe intraventricular hematoma. Neural Regen Res 2018; 13:999-1006. [PMID: 29926826 PMCID: PMC6022483 DOI: 10.4103/1673-5374.233442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The mortality rate of acute severe intraventricular hematoma is extremely high, and the rate of disability in survivors is high. Intraventricular hematoma has always been a difficult problem for clinical treatment. Although minimally invasive endoscopic hematoma evacuation is widely used to treat this disease, the technique still has room for improvement. Equipment for the intra-neuroendoscopic technique (INET) consists of two of our patented inventions: a transparent sheath (Patent No. ZL 200820046232.0) and a hematoma aspirator (Patent No. ZL 201520248717.8). This study explored the safety and efficacy of INET by comparing it with extraventricular drainage in combination with urokinase thrombolytic therapy. This trial recruited 65 patients with severe intraventricular hemorrhage, including 35 (19 men and 16 women, aged 53.2 ± 8.7 years) in the INET group and 30 (17 men and 13 women, aged 51.5 ± 7.9 years) in the control group (extraventricular drainage plus urokinase thrombolytic therapy). Our results showed that compared with the control group, the INET group exhibited lower intraventricular hemorrhage volumes, shorter intensive care-unit monitoring and ventricular drainage-tube placement times, and fewer incidences of intracranial infection, secondary bleeding, and mortality. Thus, the prognosis of survivors had improved remarkably. These findings indicate that INET is a safe and efficient new method for treating severe intraventricular hematoma. This trial was registered with ClinicalTrials.gov (NCT02515903).
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Affiliation(s)
- Bo Du
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou; Department of Emergency Medicine, Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University, Shenzhen, Guangdong Province, China
| | - Ai-Jun Shan
- Department of Emergency Medicine, Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University, Shenzhen, Guangdong Province, China
| | - Yu-Juan Zhang
- Department of Emergency Medicine, Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University, Shenzhen, Guangdong Province, China
| | - Jin Wang
- Department of Emergency Medicine, Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University, Shenzhen, Guangdong Province, China
| | - Kai-Wen Peng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Xian-Liang Zhong
- Department of Emergency Medicine, Shenzhen People's Hospital, The Second Affiliated Hospital of Jinan University, Shenzhen, Guangdong Province, China
| | - Yu-Ping Peng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
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19
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Baker AD, Rivera Perla KM, Yu Z, Dlugash R, Avadhani R, Mould WA, Ziai W, Thompson RE, Staykov D, Hanley DF. Fibrinolytic for treatment of intraventricular hemorrhage: A meta-analysis and systematic review. Int J Stroke 2017; 13:11-23. [PMID: 28920538 DOI: 10.1177/1747493017730745] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Intraventricular hemorrhage is a significant cause of mortality and morbidity worldwide. Treating intraventricular hemorrhage with intraventricular fibrinolytic therapy via a catheter is becoming an increasingly utilized intervention. Aims This meta-analysis aimed to investigate the role of intraventricular fibrinolytic treatment in hypertensive intraventricular hemorrhage patients and evaluate the effect sizes for survival as well as level of function at differing time points. Summary of review PubMed, CNKI, VIP, and Wanfang were searched using the terms "IVH" and "IVH and ICH" for human studies with adult patients published between January 1950 and July 2016. Seventeen publications were selected. Data analysis showed lower rates of mortality in the treatment group at 30 days ( P < 0.001), 180 days ( P = 0.001), 365 days ( P = 0.40), and overall ( P < 0.001). Pooling modified Rankin Scale and Glasgow outcome scale data, the treatment group had more good functional outcomes at 30 days ( P = 0.38), 90 days ( P = 0.04), 180 days ( P = 0.31), 365 days ( P = 0.76), and overall ( P = 0.02). Good functional outcome was defined as modified Rankin Scale score of 0 to 3 or a Glasgow outcome scale score of 3 to 5. Conclusions Intraventricular fibrinolytic for treatment of hypertensive intraventricular hemorrhage reduces mortality and potentially leads to an increased number of good functional outcomes. Different functional outcome scales (modified Rankin Scale or Glasgow outcome scale) produce different effect sizes. Intraventricular fibrinolytic treatment may offer intraventricular hemorrhage patients a targeted therapy that produces meaningful mortality benefit and possible functional outcome benefits.
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Affiliation(s)
- Alexandra Delaney Baker
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | | | - Zhiyuan Yu
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA.,2 Department of Neurosurgery, Sichuan University, West China School of Medicine, Chengdu, China
| | - Rachel Dlugash
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | - Radhika Avadhani
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | - William Andrew Mould
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | - Wendy Ziai
- 3 Department of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Richard E Thompson
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
| | - Dimitre Staykov
- 4 Department of Neurology, Hospital of the Brothers of St. John, Eisenstadt, Austria
| | - Daniel F Hanley
- 1 School of Medicine, Brain Injury Outcomes Division, Johns Hopkins University, Baltimore, MD, USA
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20
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Alvarez CM, Starke RM, Komotar RJ, Connolly ES. Thrombolytic Removal of Intraventricular Hemorrhage in Treatment of Severe Stroke: Results of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III Trial. Neurosurgery 2017; 81:N6-N7. [PMID: 28873991 DOI: 10.1093/neuros/nyx258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Carlos M Alvarez
- Department of Neurosurgery University of Miami Miller School of Medicine Miami, Florida
| | - Robert M Starke
- Department of Neurosurgery University of Miami Miller School of Medicine Miami, Florida
| | - Ricardo J Komotar
- Department of Neurosurgery University of Miami Miller School of Medicine Miami, Florida
| | - E Sander Connolly
- Department of Neurological Surgery Columbia University College of Physicians and Surgeons New York, New York
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21
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Lee SH, Park KJ, Park DH, Kang SH, Park JY, Chung YG. Factors Associated with Clinical Outcomes in Patients with Primary Intraventricular Hemorrhage. Med Sci Monit 2017; 23:1401-1412. [PMID: 28325888 PMCID: PMC5374890 DOI: 10.12659/msm.899309] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Primary intraventricular hemorrhage (PIVH) is an uncommon type of intracerebral hemorrhage. Owing to its rarity, the clinical and radiological factors affecting outcomes in patients with PIVH have not been widely studied. Material/Methods We retrospectively reviewed 112 patients (mean age 53 years) treated for PIVH at our institution from January 2004 to December 2014. Clinical and radiological parameters were analyzed 3 months after initial presentation to identify factors associated with clinical outcomes, as assessed by the Glasgow Outcome Scale (favorable ≥4, unfavorable <4). Results Of the 99 patients who underwent angiography, causative vascular abnormalities were found in 46%, and included Moyamoya disease, arteriovenous malformation, and cerebral aneurysm. At 3 months after initial presentation, 64% and 36% of patients were in the favorable and unfavorable outcome groups, respectively. The mortality rate was 19%. However, most survivors had no or mild deficits. Age, initial Glasgow Coma Scale (GCS) score, simplified acute physiology score (SAPS II), modified Graeb score, and various radiological parameters reflecting ventricular dilatation were significantly different between the groups. Specifically, a GCS score of less than 13 (p=0.015), a SAPS II score of less than 33 (p=0.039), and a dilated fourth ventricle (p=0.043) were demonstrated to be independent predictors of an unfavorable clinical outcome. Conclusions In this study we reveal independent predictors of poor outcome in primary intraventricular hemorrhage patients, and show that nearly half of the patients in our study had predisposing vascular abnormalities. Routine angiography is recommended in the evaluation of PIVH to identify potentially treatable etiologies, which may enhance long-term prognosis.
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Affiliation(s)
- Sang-Hoon Lee
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Kyung-Jae Park
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Dong-Hyuk Park
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Shin-Hyuk Kang
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Jung-Yul Park
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
| | - Yong-Gu Chung
- Department of Neurosurgery, Korea University Medical Center, Korea University College of Medicine, Seoul, South Korea
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22
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Guo R, Ma L, Shrestha BK, Yu Z, Li H, You C. A retrospective clinical study of 98 adult idiopathic primary intraventricular hemorrhage cases. Medicine (Baltimore) 2016; 95:e5089. [PMID: 27759637 PMCID: PMC5079321 DOI: 10.1097/md.0000000000005089] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of the study is to define the clinical features, risk factors, treatment and prognosis of idiopathic primary intraventricular hemorrhage (IPIVH).We retrospectively collected the data of consecutively admitted patients who were diagnosed and treated for IPIVH in our hospital from January 2010 to December 2014. The clinical information, treatment, and prognosis at the 6-month follow-up were analyzed.Among the 3798 cases of spontaneous intracranial hemorrhage (ICH), 98 IPIVH (2.58%) patients were recruited for the study. The study population consisted of 60 males and 38 females, with an average age (± standard deviation, SD) of 51.20 ± 15.48 years. The initial symptoms were headache (75 cases) and impaired consciousness (23 cases). The surgical treatments included hematoma evacuation under a microscope or an endoscope in 8 cases (8.16%), external ventricular drainage (EVD) in 11 cases (11.22%), lumbar drainage (LD) in 10 cases (10.20%), and a combination of EVD and LD in 11 cases (11.22%). In total, 4 patients died in the hospital (4.08%). At the 6-month follow-up, 73 patients (74.49%) had an improved outcome (modified Rankin scale [mRS] < 3), and 21 patients (21.43%) had a poor outcome (mRS ≥ 3 points) at the end of the 6-month follow-up.IPIVH is rare in clinical practice, and hypertension is the most common risk factor. Furthermore, the treatment of IPIVH is still controversial. Hematoma evacuation under a microscope or an endoscope, EVD, LD and a combination of EVD and LD could be surgical options for the treatment of IPIVH patients. The outcomes for IPIVH patients could be relatively favorable with individualized treatment.
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Affiliation(s)
| | | | | | | | | | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China
- Correspondence: Chao You, Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P.R. China (e-mail: )
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23
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Chen CW, Wu EH, Huang J, Chang WT, Ao KH, Cheng TJ, Yang W. Dynamic evolution of D-dimer level in cerebrospinal fluid predicts poor outcome in patients with spontaneous intracerebral hemorrhage combined with intraventricular hemorrhage. J Clin Neurosci 2016; 29:149-54. [PMID: 27050917 DOI: 10.1016/j.jocn.2015.10.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Chih-Wei Chen
- Division of Neurosurgery, Department of Surgery, Chi Mei Medical Center, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Taiwan; Department of Occupational Safety and Health/Institute of Industrial Safety and Disaster Prevention, College of Sustainable Environment, Chia Nan University of Pharmacy and Science, Taiwan
| | - En-Hsuan Wu
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung, Taiwan
| | - Judy Huang
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, 6128 Zayed Tower, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21218, USA
| | - Wen-Tsan Chang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Taiwan; Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Taiwan
| | - Kam-Hou Ao
- Division of Neurosurgery, Department of Surgery, Chi Mei Medical Center, Taiwan
| | - Tain-Junn Cheng
- Department of Occupational Safety and Health/Institute of Industrial Safety and Disaster Prevention, College of Sustainable Environment, Chia Nan University of Pharmacy and Science, Taiwan; Department of Neurology and Occupational Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Wuyang Yang
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, 6128 Zayed Tower, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21218, USA.
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Woo D, Kruger AJ, Sekar P, Haverbusch M, Osborne J, Moomaw CJ, Martini S, Hosseini SM, Ferioli S, Worrall BB, Elkind MSV, Sung G, James ML, Testai FD, Langefeld CD, Broderick JP, Koch S, Flaherty ML. Incontinence and gait disturbance after intraventricular extension of intracerebral hemorrhage. Neurology 2016; 86:905-11. [PMID: 26850978 DOI: 10.1212/wnl.0000000000002449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Accepted: 11/18/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We tested the hypothesis that intraventricular hemorrhage (IVH) is associated with incontinence and gait disturbance among survivors of intracerebral hemorrhage (ICH) at 3-month follow-ups. METHODS The Genetic and Environmental Risk Factors for Hemorrhagic Stroke study was used as the discovery set. The Ethnic/Racial Variations of Intracerebral Hemorrhage study served as a replication set. Both studies performed prospective hot-pursuit recruitment of ICH cases with 3-month follow-up. Multivariable logistic regression analyses were computed to identify risk factors for incontinence and gait dysmobility at 3 months after ICH. RESULTS The study population consisted of 307 ICH cases in the discovery set and 1,374 cases in the replication set. In the discovery set, we found that increasing IVH volume was associated with incontinence (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.10-2.06) and dysmobility (OR 1.58; 95% CI 1.17-2.15) after controlling for ICH location, initial ICH volume, age, baseline modified Rankin Scale score, sex, and admission Glasgow Coma Scale score. In the replication set, increasing IVH volume was also associated with both incontinence (OR 1.42; 95% CI 1.27-1.60) and dysmobility (OR 1.40; 95% CI 1.24-1.57) after controlling for the same variables. CONCLUSION ICH subjects with IVH extension are at an increased risk for developing incontinence and dysmobility after controlling for factors associated with severity and disability. This finding suggests a potential target to prevent or treat long-term disability after ICH with IVH.
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Affiliation(s)
- Daniel Woo
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL.
| | - Andrew J Kruger
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Padmini Sekar
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Mary Haverbusch
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Jennifer Osborne
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Charles J Moomaw
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Sharyl Martini
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Shahla M Hosseini
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Simona Ferioli
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Bradford B Worrall
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Mitchell S V Elkind
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Gene Sung
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Michael L James
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Fernando D Testai
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Carl D Langefeld
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Joseph P Broderick
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Sebastian Koch
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
| | - Matthew L Flaherty
- From the Department of Neurology and Rehabilitation Medicine (D.W., A.J.K., P.S., M.H., J.O., C.J.M., S.M.H., S.F., J.P.B., M.L.F.), University of Cincinnati College of Medicine, OH; Department of Neurology (S.M.), Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia School of Medicine, Charlottesville; Department of Neurology (M.S.V.E.), College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (G.S.), University of Southern California, Los Angeles; Departments of Anesthesiology and Neurology (M.L.J.), Duke University, Durham, NC; Departments of Neurology and Rehabilitation (F.D.T.), University of Illinois at Chicago; Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L.), Wake Forest School of Medicine, Winston-Salem, NC; and Miller School of Medicine (S.K.), University of Miami, FL
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Flexible Endoscopic Aspiration for Intraventricular Casting Hematoma. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 123:17-23. [PMID: 27637624 DOI: 10.1007/978-3-319-29887-0_3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Conventionally, patients suffering a massive intraventricular hemorrhage have undergone external ventricular drainage. However, long-term or repeated drainage increases the risk of complications due to infections or shunt dependency. Neuroendoscopic surgery may offer some advantages over more conventional procedures. METHODS Thirteen patients suffering intraventricular hematoma associated with intracerebral hemorrhage, treated in our hospital between April 2011 and March 2014, were reviewed retrospectively. Casting hematomas in the ventricles were manually aspirated using a flexible endoscope. The timing of the operation, period of post-endoscopic ventricular drainage, additional internal shunt surgery, 3-month post-surgical outcome, and critical complications were evaluated. RESULTS Two patients (treated during our earliest use of endoscope) who underwent surgery on the 7th and 16th day post-onset required subsequent cerebrospinal shunt surgery. In contrast, of the 11 patients who underwent endoscopic surgery on the day of onset, only 1 patient required an additional, third ventriculostomy due to a secondary obstruction of the aqueduct by adhesive fibrous membranes. After 3 months, all six patients with mRS scores of 2-3 satisfied all the following criteria: initial Glasgow Coma Scale scores higher than 8, flexible endoscopic surgeries performed on the day of onset, and period of ventricular drainage of less than 4 days. CONCLUSIONS Early surgical intervention using a flexible endoscope and short period of post-surgical drainage can be highly effective for patients suffering from casting intraventricular hematomas associated with intracerebral hemorrhage. The advantages of this treatment may be a less invasive procedure, ICP control in the acute phase, breaking away from ventricular drainage in the early stage, and prevention of hydrocephalus or intracranial infectious complications in the long term.
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Helbok R, Olson DM, Le Roux PD, Vespa P. Intracranial pressure and cerebral perfusion pressure monitoring in non-TBI patients: special considerations. Neurocrit Care 2015; 21 Suppl 2:S85-94. [PMID: 25208677 DOI: 10.1007/s12028-014-0040-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The effect of intracranial pressure (ICP) and the role of ICP monitoring are best studied in traumatic brain injury (TBI). However, a variety of acute neurologic illnesses e.g., subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, meningitis/encephalitis, and select metabolic disorders, e.g., liver failure and malignant, brain tumors can affect ICP. The purpose of this paper is to review the literature about ICP monitoring in conditions other than TBI and to provide recommendations how the technique may be used in patient management. A PubMed search between 1980 and September 2013 identified 989 articles; 225 of which were reviewed in detail. The technique used to monitor ICP in non-TBI conditions is similar to that used in TBI; however, indications for ICP monitoring often are intertwined with the presence of obstructive hydrocephalus and hence the use of ventricular catheters is more frequent. Increased ICP can adversely affect outcome, particularly when it fails to respond to treatment. However, patients with elevated ICP can still have favorable outcomes. Although the influence of ICP-based care on outcome in non-TBI conditions appears less robust than in TBI, monitoring ICP and cerebral perfusion pressure can play a role in guiding therapy in select patients.
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Affiliation(s)
- Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Innsbruck Medical University, Anichstr. 35, 6020, Innsbruck, Austria,
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Fabiano AJ, Gruber TJ, Baxter MS. Increased ventriculostomy infection rate with use of intraventricular tissue plasminogen activator: A single-center observation. Clin Neurol Neurosurg 2013; 115:2362-4. [DOI: 10.1016/j.clineuro.2013.08.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/16/2013] [Accepted: 08/18/2013] [Indexed: 11/30/2022]
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Clearing bloody cerebrospinal fluid: clot lysis, neuroendoscopy and lumbar drainage. Curr Opin Crit Care 2013; 19:92-100. [PMID: 23337912 DOI: 10.1097/mcc.0b013e32835cae5e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Bloody cerebrospinal fluid (CSF) is a major cause of morbidity and mortality in intraventricular hemorrhage (IVH) and subarachnoid hemorrhage (SAH). Different treatment strategies aiming at faster clearance of bloody CSF have emerged. The present review focuses on recent developments in the investigation of those treatments. RECENT FINDINGS Intraventricular fibrinolysis (IVF) for accelerated IVH-resolution has been clinically tested since the early 1990s. The lately summarized evidence from smaller studies indicates that IVF may result in a benefit in mortality and outcome. Recent investigations have elucidated different aspects of IVF, mainly related to safety. Neuroendoscopy has also emerged as a minimally invasive technique allowing fast removal of IVH. The capability of lumbar drainage to reduce vasospasm after SAH has been tested in a large trial. SUMMARY IVF is relatively well tolerated and accelerates clot clearance after IVH. The effect of IVF on clinical outcome and mortality is currently being investigated in a large-scale phase III clinical trial. Neuroendoscopy is feasible for the treatment of IVH, however, larger trials are lacking. Lumbar drainage reduces the incidence of vasospasm after SAH. An ongoing phase III trial has been designed to test its influence on outcome. Lumbar drainage may also reduce shunt-dependency after IVH.
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Ziai WC, Tuhrim S, Lane K, McBee N, Lees K, Dawson J, Butcher K, Vespa P, Wright DW, Keyl PM, Mendelow AD, Kase C, Wijman C, Lapointe M, John S, Thompson R, Thompson C, Mayo S, Reilly P, Janis S, Awad I, Hanley DF. A multicenter, randomized, double-blinded, placebo-controlled phase III study of Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage (CLEAR III). Int J Stroke 2013; 9:536-42. [PMID: 24033910 DOI: 10.1111/ijs.12097] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 04/16/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND In adults, intraventricular thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) facilitates resolution of intraventricular haemorrhage (IVH), reduces intracranial pressure, decreases duration of cerebrospinal fluid diversion, and may ameliorate direct neural injury. We hypothesize that patients with small parenchymal haematoma volumes (<30 cc) and relatively large IVH causing acute obstructive hydrocephalus would have improved clinical outcomes when given injections of low-dose rtPA to accelerate lysis and evacuation of IVH compared with placebo. METHODS The Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage III trial is an investigator-initiated, phase III, randomized, multicenter, double-blind, placebo-controlled study comparing the use of external ventricular drainage (EVD) combined with intraventricular injection of rtPA to EVD plus intraventricular injection of normal saline (placebo) for the treatment of IVH. Patients with known symptom onset within 24 h of the computed tomography scan confirmed IVH and third or fourth ventricle obstruction, with or without supratentorial intracerebral haemorrhage volume <30 cc, who require EVD are screened with a computed tomography scan at least six hours after EVD placement and, if necessary, at consecutive 12-h intervals until stabilization of any intracranial bleeding has been established. Patients who meet clinical and imaging criteria (no ongoing coagulopathy and no suspicion of aneurysm, arteriovenous malformation, or any other vascular anomaly) will be randomized to either intraventricular rtPA or placebo. RESULTS The primary outcome measure is dichotomized modified Rankin Scale 0-3 vs. 4-6 at 180 days. Clinical secondary outcomes include additional modified Rankin Scale dichotomizations at 180 days (0-4 vs. 5-6), ordinal modified Rankin Scale (0-6), mortality and safety events at 30 days, mortality at 180 days, functional status measures, type and intensity of intensive care unit management, rate and extent of ventricular blood clot removal, and quality of life measures.
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Affiliation(s)
- Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Jackson DA, Patel AV, Darracott RM, Hanel RA, Freeman WD, Hanley DF. Safety of intraventricular hemorrhage (IVH) thrombolysis based on CT localization of external ventricular drain (EVD) fenestrations and analysis of EVD tract hemorrhage. Neurocrit Care 2013; 19:103-10. [PMID: 22544476 PMCID: PMC3785325 DOI: 10.1007/s12028-012-9713-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of the study is to review the CT findings associated with ventriculostomy placement in regards to the safety of an EVD plus recombinant tissue plasminogen activator (rt-PA) for IVH. METHODS A retrospective review was conducted for patients receiving intraventricular rt-PA for IVH from January 2004 to September 2009. Safety was assessed by the presence of EVD tract hemorrhage by CT at baseline after EVD placement, worsening hemorrhage after rt-PA, and CSF infection. IVH volumetrics were assessed by the Le Roux score and outcomes by Glasgow Outcome Scale and modified Rankin Scale. RESULTS Twenty-seven patients received rt-PA for IVH. Median dose was 2 mg (range 0.3-8) and a median of two doses (range 1-17) were given. Worsening EVD catheter tract hemorrhage after rt-PA was 46.7 %, with a significantly higher incidence of worsening tract hemorrhage seen with incorrectly placed EVDs (p = 0.04). IVH hematoma burden decreased by a median Le Roux score of 10 (range 3-16) prior to rt-PA to 4 (range 0-16) after rt-PA. There were no central nervous system bacterial infections. CONCLUSION Intraventricular rt-PA appears to be relatively safe especially when all EVD fenestrations are within the ventricle and reduces IVH burden similar to other studies. We describe a CT-based EVD tract hemorrhage grading scale to evaluate EVD tract hemorrhage before and after thrombolysis, and a bone-window technique to evaluate EVD fenestrations prior to IVH thrombolysis. Further research is needed evaluating these imaging techniques in regard to intraventricular thrombolytic safety and EVD tract hemorrhage.
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Affiliation(s)
| | - Alden V. Patel
- Department of Pharmacy, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - William D. Freeman
- Departments of Neurology and Critical Care, Mayo Clinic, 4500, San Pablo Road, Jacksonville, FL 32224, USA
| | - Daniel F. Hanley
- Departments of Neurology, Neurosurgery, and Anesthesiology & Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
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El Ahmadieh TY, Adel JG, El Tecle NE, Daou MR, Aoun SG, Nanney AD, Bendok BR. Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring. Neurosurg Clin N Am 2013; 24:375-91. [PMID: 23809032 DOI: 10.1016/j.nec.2013.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.
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Affiliation(s)
- Tarek Y El Ahmadieh
- Department of Neurological Surgery, McGaw Medical Center, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 2210, Chicago, IL 60611, USA
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Basaldella L, Marton E, Fiorindi A, Scarpa B, Badreddine H, Longatti P. External ventricular drainage alone versus endoscopic surgery for severe intraventricular hemorrhage: a comparative retrospective analysis on outcome and shunt dependency. Neurosurg Focus 2012; 32:E4. [PMID: 22463114 DOI: 10.3171/2012.1.focus11349] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Massive intraventricular hemorrhages (IVHs) require aggressive and rapid management to decrease intracranial hypertension, because the amount of intraventricular blood is a strong negative prognostic predictor on outcome. Neuroendoscopy may offer some advantages over more traditional surgical approaches on outcome and may decrease the number of shunt procedures that need to be performed. METHODS The authors retrospectively reviewed the clinical and radiological data in 96 patients treated for massive IVH who were admitted between January 1996 and June 2008 to the neurosurgery unit after undergoing emergency CT scanning. Forty-eight patients (Group A) were treated with endoscopic aspiration surgery using a flexible endoscope with a "freehand" technique. A historical group of 48 patients (Group B) treated using external ventricular drain (EVD) placement alone was used as a comparison. The authors compared the radiological results with the clinical outcomes at 1 year according to the modified Rankin Scale and the need for internal CSF shunt treatment in the 2 groups. RESULTS Endoscopic aspiration did not significantly affect the outcome at 1 year as determined using the modified Rankin Scale. Patients who underwent endoscopy had an EVD in place for 0.18 days fewer than patients treated with an EVD alone. Patients undergoing external ventricular drainage alone had a 5 times greater chance of requiring a shunting procedure than those treated using neuroendoscopy and external ventricular drainage. Neuroendoscopy plus external drainage reduces shunting rates by 34% when compared with external drainage alone. CONCLUSIONS The reduction in internal shunt surgery encourages the adoption of neuroendoscopic aspiration of severe IVH as a therapeutic tool to decrease shunt dependency.
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Affiliation(s)
- Luca Basaldella
- Department of Neurosurgery, Treviso Regional Hospital, University of Padova, Treviso, Italy.
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Hinson HE, Melnychuk E, Muschelli J, Hanley DF, Awad IA, Ziai WC. Drainage efficiency with dual versus single catheters in severe intraventricular hemorrhage. Neurocrit Care 2012; 16:399-405. [PMID: 21681594 DOI: 10.1007/s12028-011-9569-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about the efficacy of single versus dual extraventricular drain (EVD) use in intraventricular hemorrhage (IVH), with and without thrombolytic therapy. METHODS Post-hoc analysis of seven patients with dual bilateral EVDs from two multicenter trials involving 100 patients with IVH, and spontaneous intracerebral hemorrhage (ICH) volume <30 ml requiring emergency external ventricular drainage. Seven "control" patients with single catheters were matched by IVH volume and distribution and treatment assignment. Head CT scans were obtained daily during intraventricular injections for quantitative determination of IVH volume. RESULTS Median [min-max] age of the 14 subjects was 56 [40-73] years. Median duration of EVD was 7.9 days (single catheter group) versus 12.2 days (dual catheter group) (P = 0.34). Baseline median IVH volume was not significantly different between groups (75.4 ml [22.4-105.1]--single EVD vs. 84.5 ml [42.0-132.0]--dual EVD; P = 0.28). Comparing the change in IVH volume on time-matched CT scans during dual EVD use, the median decrease in IVH volume in dual catheter patients was significantly larger (52.1 [31.7-81.1] ml) versus single catheter patients (34.5 [13.1-73.9] ml) (P = 0.004). There was a trend to greater decrease in IVH volume during dual EVD use in both rt-PA (P = 0.9) and placebo-treated (P = 0.11) subgroups. CONCLUSION The decision to place dual EVDs is generally reserved for large IVH (>40 ml) with casting and mass effect. The use of dual simultaneous catheters may increase clot resolution with or without adjunctive thrombolytic therapy.
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Affiliation(s)
- Holly E Hinson
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Meyer 8-140, 600 N Wolfe St, Baltimore, MD, USA.
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Characteristics and Sequelae of Intracranial Hypertension After Intracerebral Hemorrhage. Neurocrit Care 2012; 17:172-6. [DOI: 10.1007/s12028-012-9744-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Occurrence and impact of intracranial pressure elevation during treatment of severe intraventricular hemorrhage. Crit Care Med 2012; 40:1601-8. [PMID: 22430237 DOI: 10.1097/ccm.0b013e318241e380] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Elevated intracranial pressure is one of the proposed mechanisms leading to poor outcomes in patients with intraventricular hemorrhage. We sought to characterize the occurrence and significance of intracranial hypertension in severe intraventricular hemorrhage requiring extraventricular drainage. DESIGN Prospective analysis from two randomized, multicenter, clinical trials. SETTING Intensive care units of 23 academic hospitals. PATIENTS One hundred patients with obstructive intraventricular hemorrhage and intracerebral hemorrhage volume <30 mL requiring emergency extraventricular drainage from two randomized multicenter studies comparing intraventricular recombinant tissue plasminogen activator (n=78) to placebo (n=22). INTERVENTIONS Intracranial pressure was recorded every 4 hrs in all patients and before and after a 1-hr extraventricular drainage closure period after injection. Intracranial pressure readings were analyzed at predefined thresholds and compared between treatment groups, before and after injection of study agent, and before and after opening of third and fourth ventricles on computed tomography. Impact on 30-day outcomes was assessed. MEASUREMENTS AND MAIN RESULTS Initial intracranial pressure ranged from -2 to 60 mm Hg (median; interquartile range, 11;10). Of 2576 intracranial pressure readings, 91.5% (2359) were ≤20 mm Hg, 1.6% were >30, 0.5% were >40, and 0.2% were >50 mm Hg. In a multivariate analysis, threshold events>20 mm Hg and >30 mm Hg were more frequent in placebo vs. recombinant tissue plasminogen activator-treated groups (p=.03 and p=.08, respectively). Intracranial pressure elevation>20 mm Hg occurred during a required 1-hr extraventricular drainage closure interval in 207 of 868 (23.8%) injections of study agent, although early reopening of the extraventricular drainage only occurred in 7.9%. After radiographic opening of the lower ventricular system, intracranial pressure events>20 mm Hg remained significantly associated with initial intraventricular hemorrhage volume (p=.002) and extraventricular drainage placement ipsilateral to the largest intraventricular hemorrhage volume (p=.001), but not with thrombolytic treatment (p=.05) or intracerebral hemorrhage volume (p=.14). Ventriculoperitoneal shunts were required in 13.6% of placebo and 6.4% of recombinant tissue plasminogen activator-treated patients (p=.37). Percentage of intracranial pressure readings per patient>30 mm Hg and initial intracerebral hemorrhage and intraventricular hemorrhage volumes were independent predictors of 30-day mortality after adjustment for other outcome predictors (p=.003, p=.03, and p<.001, respectively). Independent predictors of poor modified Rankin Scale score at 30 days were percent of intracranial pressure events>30 mm Hg per patient (p=.01; but not >20 mm Hg), both intracerebral hemorrhage and intraventricular hemorrhage volume, and pulse pressure. CONCLUSIONS Intracranial pressure is not frequently elevated during monitoring and drainage with an extraventricular drainage in patients with severe intraventricular hemorrhage, although intracranial pressure >30 mm Hg predicts higher short-term mortality. Thrombolytic therapy may reduce the frequency of high intracranial pressure events. Intracranial pressure elevation appears to be significantly correlated with extraventricular drainage placement in the ventricle with greatest clot volume.
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King NKK, Lai JL, Tan LB, Lee KK, Pang BC, Ng I, Wang E. A randomized, placebo-controlled pilot study of patients with spontaneous intraventricular haemorrhage treated with intraventricular thrombolysis. J Clin Neurosci 2012; 19:961-4. [PMID: 22595353 DOI: 10.1016/j.jocn.2011.09.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 09/26/2011] [Accepted: 09/28/2011] [Indexed: 12/01/2022]
Abstract
Intraventricular hemorrhage (IVH) occurring after spontaneous intracerebral hemorrhage (ICH) is an independent risk factor for mortality. The use of intraventricular urokinase (Uk) to reduce intraventricular blood clot volume and improve outcome was investigated. Patients with IVH requiring external ventricular drainage were recruited and randomized into a double-blind placebo controlled study. Assessments of collected cerebrospinal fluid (CSF) haemoglobin (Hb) and serial CT scans were performed. The study outcomes were: infection rates, length of stay in the intensive care unit, survival, National Institutes of Health Stroke Scale score; and modified Rankin Scale scores. Our results showed an increase in both the drained CSF Hb concentration in patients treated with Uk compared to placebo and in the rate of resolution clot volume. No differences were found in the other outcome measures but there was a trend towards lowered mortality in the group treated with Uk. Therefore, intraventricular Uk resulted in faster resolution of IVH with no adverse events.
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Affiliation(s)
- Nicolas K K King
- Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore.
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Rincon F, Mayer SA. Intracerebral hemorrhage: clinical overview and pathophysiologic concepts. Transl Stroke Res 2012; 3:10-24. [PMID: 24323860 DOI: 10.1007/s12975-012-0175-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/09/2012] [Accepted: 04/11/2012] [Indexed: 10/28/2022]
Abstract
Intracerebral hemorrhage is by far the most destructive form of stroke. Apart from the management in a specialized stroke or neurological intensive care unit (NICU), no specific therapies have been shown to consistently improve outcomes after ICH. Current guidelines endorse early aggressive optimization of physiologic derangements with ventilatory support when indicated, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring for certain cases, osmotherapy, temperature modulation, seizure prophylaxis, treatment of hyerglycemia, and nutritional support in the stroke unit or NICU. Ventriculostomy is the cornerstone of therapy for control of intracranial pressure patients with intraventricular hemorrhage. Surgical hematoma evacuation does not improve outcome for more patients, but is a reasonable option for patients with early worsening due to mass effect due to large cerebellar or lobar hemorrhages. Promising experimental treatments currently include ultra-early hemostatic therapy, intraventricular clot lysis with thrombolytics, pioglitazone, temperature modulation, and deferoxamine to reduce iron-mediated perihematomal inflammation and tissue injury.
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Affiliation(s)
- Fred Rincon
- Department of Neurology and Neurosurgery, Division of Critical Care and Neurotrauma, Thomas Jefferson University, Philadelphia, PA, USA
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Intraventricular fibrinolysis for intracerebral hemorrhage with severe ventricular involvement. Neurocrit Care 2012; 15:194-209. [PMID: 20524079 DOI: 10.1007/s12028-010-9390-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Intraventricular hemorrhage (IVH) has been associated with poor prognosis in patients with spontaneous intracerebral hemorrhage. Several factors contribute to the deleterious effects of IVH, including direct mass effects of the ventricular blood clot on ependymal and subependymal brain structures, mechanical and inflammatory impairment of the Pacchioni granulations by blood and its breakdown products, and disturbance of physiological cerebrospinal fluid (CSF) circulation. Acute obstructive hydrocephalus represents a major life-threatening complication of IVH and is usually treated with an external ventricular drainage (EVD). However, treatment with EVD alone is frequently not sufficiently effective due to obstruction of the catheter by blood. In the past two decades, intraventricular fibrinolysis (IVF) has been increasingly used for maintenance of EVD functionality and acceleration of ventricular clot resolution in such patients. Unfortunately, there is no prospective, randomized controlled trial addressing the effect of IVF on clinical outcome. The available data on IVF consist of small retrospective case series, case reports, and a few prospective case-control studies, which are the subject of the present review article. All these studies, when considered in their entirety, suggest that IVF has a positive impact on mortality and functional outcome, and could be considered as a treatment option for selected patients.
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Dunatov S, Antoncic I, Bralic M, Jurjevic A. Intraventricular thrombolysis with rt-PA in patients with intraventricular hemorrhage. Acta Neurol Scand 2011; 124:343-8. [PMID: 21303348 DOI: 10.1111/j.1600-0404.2010.01481.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To evaluate safety, clinical feasibility, and outcome of intraventricular (IVen) administration of recombinant tissue plasminogen activator (rt-PA) in patients with intraventricular hemorrhage (IVH). MATERIALS AND METHODS Forty-eight patients with IVH who received IVen rt-PA were compared with 49 age-, sex-, Glasgow Coma Scale score-, and Intracerebral Hemorrhage score-matched control patients. Patients with IVH of aneurysmal or arteriovenous malformation origin were excluded. External ventricular drainage was inserted as soon as baseline CT was performed and rt-PA was administered within 12 ± 1 h after the ictal onset. RESULTS The outcome after 3 months was evaluated using the modified Rankin Scale (mRS). In addition, Glasgow Outcome Scale (GOS) and mortality were assessed. A good outcome, defined as mRS 0-3, was detected in 27% of patients from the control group vs 58% of patients in the IVen group; P = 0.003. GOS as other outcome scale yielded a significant difference between groups: 20% in the control group, vs 54% in the IVen group; P = 0.001. A statistically significant decrease in mortality was observed in the IVen group: 30% in the control vs 10% in IVen group; P = 0.003. No one patient died because of a complication which could be directly attributed to the IVen thrombolytic therapy. CONCLUSIONS IVen administration of rt-PA seems to be safe in cases of IVH. This pilot study shows that it may be associated with better outcomes. Further studies and clinical randomized trials are needed to establish indications and IVen administration protocols.
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Affiliation(s)
- S Dunatov
- Intensive Care Unit, Department of Neurology, Clinical Hospital Centre Rijeka, Croatia.
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Naff N, Williams MA, Keyl PM, Tuhrim S, Bullock MR, Mayer SA, Coplin W, Narayan R, Haines S, Cruz-Flores S, Zuccarello M, Brock D, Awad I, Ziai WC, Marmarou A, Rhoney D, McBee N, Lane K, Hanley DF. Low-dose recombinant tissue-type plasminogen activator enhances clot resolution in brain hemorrhage: the intraventricular hemorrhage thrombolysis trial. Stroke 2011; 42:3009-16. [PMID: 21868730 DOI: 10.1161/strokeaha.110.610949] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Patients with intracerebral hemorrhage and intraventricular hemorrhage have a reported mortality of 50% to 80%. We evaluated a clot lytic treatment strategy for these patients in terms of mortality, ventricular infection, and bleeding safety events, and for its effect on the rate of intraventricular clot lysis. METHODS Forty-eight patients were enrolled at 14 centers and randomized to treatment with 3 mg recombinant tissue-type plasminogen activator (rtPA) or placebo. Demographic characteristics, severity factors, safety outcomes (mortality, infection, bleeding), and clot resolution rates were compared in the 2 groups. RESULTS Severity factors, including admission Glasgow Coma Scale, intracerebral hemorrhage volume, intraventricular hemorrhage volume, and blood pressure were evenly distributed, as were adverse events, except for an increased frequency of respiratory system events in the placebo-treated group. Neither intracranial pressure nor cerebral perfusion pressure differed substantially between treatment groups on presentation, with external ventricular device closure, or during the active treatment phase. Frequency of death and ventriculitis was substantially lower than expected and bleeding events remained below the prespecified threshold for mortality (18% rtPA; 23% placebo), ventriculitis (8% rtPA; 9% placebo), symptomatic bleeding (23% rtPA; 5% placebo, which approached statistical significance; P=0.1). The median duration of dosing was 7.5 days for rtPA and 12 days for placebo. There was a significant beneficial effect of rtPA on rate of clot resolution. CONCLUSIONS Low-dose rtPA for the treatment of intracerebral hemorrhage with intraventricular hemorrhage has an acceptable safety profile compared to placebo and historical controls. Data from a well-designed phase III clinical trial, such as CLEAR III, will be needed to fully evaluate this treatment.
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Affiliation(s)
- Neal Naff
- Sandra and Malcolm Berman Brain & Spine Institute, Department of Neurology, Sinai Hospital of Baltimore, MD, USA
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Intraventricular Hemorrhage. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10070-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Brain hemorrhage is the most fatal form of stroke and has the highest morbidity of any stroke subtype. Intraventricular extension of hemorrhage (IVH) is a particularly poor prognostic sign, with expected mortality between 50% and 80%. IVH is a significant and independent contributor to morbidity and mortality, yet therapy directed at ameliorating intraventricular clot has been limited. Conventional therapy centers on managing hypertension and intracranial pressure while correcting coagulopathy and avoiding complications such as rebleeding and hydrocephalus. Surgical therapy alone has not changed the natural history of the disease significantly. However, fibrinolysis in combination with extraventricular drainage shows promise as a technique to reduce intraventricular clot volume and to manage the concomitant complications of IVH.
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Xu F, Tang Z, Luo X, Kang H, Hu Q, Zhu S. No evidence of preoperative hematoma growth representing an increased postoperative rebleeding risk for minimally invasive aspiration and thrombolysis of ICH. Br J Neurosurg 2010; 24:268-74. [DOI: 10.3109/02688691003624588] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
OBJECTIVE Acute intracranial hemorrhage and intraventricular hemorrhage are devastating disorders. The goal of this review is to familiarize clinicians with recent information pertaining to the acute care of intracranial hemorrhage and intraventricular hemorrhage. DATA SOURCES PubMed search and review of the relevant medical literature. SUMMARY The management of intracranial hemorrhage and intraventricular hemorrhage is complex. Effective treatment should include strategies designed to reduce hematoma expansion and limit the medical consequences of intracranial hemorrhage and intraventricular hemorrhage. At present, there are a number of new approaches to treatment that may reduce mortality and improve clinical outcomes. Clinicians should recognize that patients with large hematomas may make a substantial recovery. CONCLUSIONS Patients with intracranial hemorrhage and intraventricular hemorrhage should be cared for in an intensive care unit. New therapies designed to stabilize hematoma growth and reduce hematoma burden may improve outcomes.
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Affiliation(s)
- Paul Nyquist
- Neurology/Anesthesiology Critical Care Medicine/ Neurosurgery, Johns Hopkins School of Medicine, Baltimore Maryland, USA.
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Abstract
PURPOSE OF REVIEW Spontaneous intracerebral hemorrhage (ICH) is the most devastating type of stroke and a leading cause of disability and mortality in the United States and the rest of the world. The purpose of this article is to review recent advances in the management of spontaneous intracerebral hemorrhage. RECENT FINDINGS Although no interventions have consistently shown an improvement of mortality or functional outcomes after ICH, results from multicenter prospective randomized controlled trials have shown that early hemostasis to prevent hematoma growth, removal of clot by surgical or minimally invasive interventions, clearance of intraventricular hemorrhage, and adequate blood pressure control for the optimization of cerebral perfusion pressure may constitute the most important therapeutic goals to ameliorate secondary neurological damage, decrease mortality, and improve functional outcomes after ICH. CONCLUSION Several promising methods may be ready for routine clinical use in a few years to decrease disability and mortality from ICH.
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Huttner HB, Staykov D, Bardutzky J, Nimsky C, Richter G, Doerfler A, Schwab S. [Treatment of intraventricular hemorrhage and hydrocephalus]. DER NERVENARZT 2009; 79:1369-70, 1372-4, 1376. [PMID: 18626618 DOI: 10.1007/s00115-008-2515-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Most cases of intraventricular hemorrhage (IVH) occur secondary to spontaneous intracerebral or subarachnoid hemorrhage. The main concern is development of hydrocephalus, which is related to a poor prognosis. Over the last years, several treatment options for IVH have been introduced, but prospective data regarding the efficacy of those therapies (external ventricular drainage, intraventricular fibrinolysis, lumbar drainage, endoscopic hematoma evacuation) do not yet exist. This review focuses on combined therapy using an external ventricular drain and intraventricular fibrinolysis with r-TPA for IVH-associated initial occlusive hydrocephalus. Moreover, a continuing treatment strategy for persistent malresorptive communicating hydrocephalus using lumbar drainage is described.
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Affiliation(s)
- H B Huttner
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen.
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Ziai WC, Torbey MT, Naff NJ, Williams MA, Bullock R, Marmarou A, Tuhrim S, Schmutzhard E, Pfausler B, Hanley DF. Frequency of sustained intracranial pressure elevation during treatment of severe intraventricular hemorrhage. Cerebrovasc Dis 2009; 27:403-10. [PMID: 19295201 DOI: 10.1159/000209241] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Accepted: 09/11/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Elevated intracranial pressure (ICP) is an important marker of neurological deterioration. The occurrence and significance of elevated ICP and low cerebral perfusion pressure (CPP) in aggressively treated spontaneous intraventricular hemorrhage (IVH) are not defined. METHODS We performed a secondary longitudinal exploratory data analysis of a randomized multicenter trial of urokinase (UK) versus placebo (Pcb) as a treatment for IVH. Eleven IVH patients who required an external ventricular drain (EVD) were randomized to receive either intraventricular UK or Pcb every 12 h until clinical response permitted EVD removal. ICP and CPP were recorded every 4 or 6 h, as well as before and 1 h after EVD closure for administration of study agent. ICP, CPP and the proportion of ICP readings above 20, 30, 40 and 50 mm Hg were analyzed. RESULTS Six UK and 5 Pcb patients aged 39-74 years (mean +/- standard deviation; 53 +/- 11 years) were enrolled. Initial ICP ranged from 0 to 38 mm Hg (10.9 +/- 11.0), initial CPP from 65 to 133 mm Hg (100.5 +/- 17.7). We recorded 472 ICP readings over the entire monitoring period. Of these 65 (14%) were >20 mm Hg, 23 (5%) >30 mm Hg, 9 (2%) >40 mm Hg and 3 (<1%) >50 mm Hg. Only 2 of 141 intraventricular injections of study agent with EVD closure were not tolerated and required reopening of the EVD. CONCLUSIONS In the intensive care unit, initial ICP measured with an EVD was uncommonly elevated (1/11 patients) in this group of severe IVH patients despite acute obstructive hydrocephalus. Frequent monitoring reveals ICP elevation >20 mm Hg in 14% of observations during use of EVD. ICP elevation, though it can occur, is not routinely associated with EVD closure for thrombolytic treatment with UK.
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Affiliation(s)
- Wendy C Ziai
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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