Lysis of intraventricular blood clot with urokinase in a canine model: Part 1. Canine intraventricular blood cast model

Dramatic Reanimation and Spontaneous Re-Canalization of a Fourth Ventricular Hemorrhage: "REVIVE" Phenomenon

Background

Intraventricular hemorrhage is a calamitous type of stroke where bleeding into the ventricular system can be defined as: primary, if confined within the ventricles; or secondary, due to intracerebral hemorrhage extending from adjacent parenchyma. Intraventricular blood clot can lead to secondary insult and inflammatory responses that culminates in hydrocephalus as the most common cause of death.

Purpose

THerein, we report a patient with a high modified Graeb scale and low Glasgow coma scale. She spontaneously recanalized her fourth ventricle, decompressed her reticular activating system with remarkable spontaneous bilateral eye opening, and a consequently experienced a halfway drop in her mGS.

Results

This is the first reported case of a spontaneous recanalization of 4th ventricle obstruction secondary to IVH without intervention and subsequent dramatic neurological improvement. We believe that the apixaban primarily preserved the liquid state of hemorrhage and her presumed elevated ICP was sufficient to push out the liquified blood in the 4th ventricle into the upper spinal canal , recanalizing the 4th ventricle by continuously creating downward CSF pressure waves. Given the RAS location around the 4th ventricle, we hypothesize spontaneous decompression from the clot lysis triggered the RAS activation with sudden arousal manifested as spontaneous bilateral eyes opening. Hence, we refer to this as the reticular activating system reactivation after ventricular hemorrhage evacuation, or simply the "REVIVE" phenomenon.

Conclusion

This dramatic improvement from coma to awake state is worthy of recognition for future neurotherapeutic interventions.

Natural History, Pathophysiology, and Recent Management Modalities of Intraventricular Hemorrhage

Intraventricular hemorrhage (IVH) is a clinical challenge observed among 40-45% of intracerebral hemorrhage (ICH) cases. IVH can be classified according to the source of the hemorrhage into primary and secondary IVH. Primary intraventricular hemorrhage (PIVH), unlike secondary IVH, involves only the ventricles with no hemorrhagic parenchymal source. Several risk factors of PIVH were reported which include hypertension, smoking, age, and excessive alcohol consumption. IVH is associated with high mortality and morbidity and several prognostic factors were identified such as IVH volume, number of ventricles with blood, involvement of fourth ventricle, baseline Glasgow Coma Scale score, and hydrocephalus. Prompt management of patients with IVH is required to stabilize the clinical status of patients upon admission. Nevertheless, further advanced management is crucial to reduce the morbidity and mortality associated with intraventricular bleeding. Recent treatments showed promising outcomes in the management of IVH patients such as intraventricular anti-inflammatory drugs, lumbar drainage, and endoscopic evacuation of IVH, however, their safety and efficacy are still in question. This literature review presents the epidemiology, physiopathology, risk factors, and outcomes of IVH in adults with an emphasis on recent treatment options.

Posttraumatic hydrocephalus: Recent advances and new therapeutic strategies

Background

Hydrocephalus or ventriculomegaly is a condition brought on by an overabundance of cerebrospinal fluid (CSF) in the ventricular system. The major contributor to posttraumatic hydrocephalus (PTH) is traumatic brain injuries (TBIs), especially in individuals with occupations set in industrial settings. A variety of criteria have been employed for the diagnosis of PTH, including the combination of neurological symptoms like nerve deficits and headache, as well as an initial improvement followed by a worsened relapse of altered consciousness and neurological deterioration, which is detected by computed tomography-brain imaging that reveals gradual ventriculomegaly.

Aim

In this article, we discuss and summarize briefly the current understandings and advancements in the management of PTH.

Methods

The available literature for this review was searched on various bibliographic databases using an individually verified, prespecified approach. The level of evidence of the included studies was considered as per the Centre for Evidence-Based Medicine recommendations.

Results

The commonly practiced current treatment modality involves shunting CSF but is often associated with complications and recurrence. The lack of a definitive management strategy for PTH warrants the utilization of novel and innovative modalities such as stem cell transplantations and antioxidative stress therapies.

Conclusion

One of the worst complications of a TBI is PTH, which has a high morbidity and mortality rate. Even though there hasn't been a successful method in stopping PTH from happening, hemorrhage-derived blood, and its metabolic by-products, like iron, hemoglobin, free radicals, thrombin, and red blood cells, may be potential targets for PTH hindrance and management. Also, using stem cell transplantations in animal models and antioxidative stress therapies in future studies can lower PTH occurrence and improve its outcome. Moreover, the integration of clinical trials and theoretical knowledge should be encouraged in future research projects to establish effective and updated management guidelines for PTH.

Minimally Invasive Surgery for Intracerebral and Intraventricular Hemorrhage

Spontaneous intracerebral hemorrhage (ICH), especially related to intraventricular hemorrhage (IVH), is the most devastating type of stroke and is associated with high mortality and morbidity. Optimal management of ICH remains one of the most controversial areas of neurosurgery and no effective treatment exists for ICH. Studies comparing conventional surgical interventions with optimal medical management failed to show significant benefit. Recent exploration of minimally invasive surgery for ICH and IVH including catheter- and mechanical-based approaches has shown great promise. Early phase clinical trials have confirmed the safety and preliminary treatment effect of minimally invasive surgery for ICH and IVH. Pending efficacy data from phase III trials dealing with diverse minimally invasive techniques are likely to shape the treatment of ICH.

Blood-Brain Barrier Dysfunction After Smoke Inhalation Injury, With and Without Skin Burn

Only a handful of published reports exist today that describe neurological complications following smoke inhalation injury. In this study, we characterize acute pathophysiological changes in the brain of sheep exposed to smoke inhalation, with- and without third-degree skin burn that models the injuries sustained by human victims of fire accidents. Blood-brain barrier integrity and hemorrhage were analyzed throughout the brain using specific histological stains: Hematoxylin & Eosin, Luxol fast blue, Periodic acid-Schiff (PAS), and Martius, Scarlet and Blue (MSB). Our data show that, following smoke inhalation injury, alone and in combination with third-degree skin burn, there was a significant increase in the number of congested and dilated blood vessels in the frontal cortex, basal ganglia, amygdala, hippocampus, pons, cerebellum, and pituitary gland as compared to sham-injured controls. Positive PAS staining confirmed damage to the basement membrane of congested and dilated blood vessels throughout the brain. Severe rupturing of blood vessels, microvascular hemorrhaging and bleeding throughout the brain was also observed in the injured groups. No significant changes in hemodynamics and PaO2 were observed. Our data demonstrate for the first time that acute smoke inhalation alone results in diffuse blood-brain barrier dysfunction and massive bleeding in the brain in the absence of hypoxia and changes in hemodynamics. These findings provide critical information and prompt further mechanistic and interventional studies necessary to develop effective and novel treatments aimed at alleviating CNS dysfunction in patients with smoke and burn injuries.

Intracerebral Hemorrhage

PURPOSE OF REVIEW

This article describes the advances in the management of spontaneous intracerebral hemorrhage in adults.

RECENT FINDINGS

Therapeutic intervention in intracerebral hemorrhage has continued to focus on arresting hemorrhage expansion, with large randomized controlled trials addressing the effectiveness of rapidly lowering blood pressure, hemostatic therapy with platelet transfusion, and other clotting complexes and clot volume reduction both of intraventricular and parenchymal hematomas using minimally invasive techniques. Smaller studies targeting perihematomal edema and inflammation may also show promise.

SUMMARY

The management of spontaneous intracerebral hemorrhage, long relegated to the management and prevention of complications, is undergoing a recent evolution in large part owing to stereotactically guided clot evacuation techniques that have been shown to be safe and that may potentially improve outcomes.

Uncovering the Rosetta Stone: Report from the First Annual Conference on Key Elements in Translating Stroke Therapeutics from Pre-Clinical to Clinical

The first annual Stroke Translational Research Advancement Workshop (STRAW), entitled “Uncovering the Rosetta Stone: Key Elements in Translating Stroke Therapeutics from Pre-Clinical to Clinical” was held at the University of Kentucky on October 4–5, 2017. This workshop was organized by the Center for Advanced Translational Stroke Science. The workshop consisted of 2 days of activities. These included three presentations establishing the areas of research in stroke therapeutics, discussing the routes for translation from bench to bedside, and identifying successes and failures in the field. On day 2, grant funding opportunities and goals for the National Institute for Neurological Diseases and Stroke were presented. In addition, the meeting also included break-out sessions designed to connect researchers in areas of stroke, and to foster potential collaborations. Finally, the meeting concluded with an open discussion among attendees led by a panel of experts.

Challenges for intraventricular hemorrhage research and emerging therapeutic targets

INTRODUCTION

Intraventricular hemorrhage (IVH) affects both premature infants and adults. In both demographics, it has high mortality and morbidity. There is no FDA approved therapy that improves neurological outcome in either population highlighting the need for additional focus on therapeutic targets and treatments emerging from preclinical studies. Areas covered: IVH induces both initial injury linked to the physical effects of the blood (mass effect) and secondary injury linked to the brain response to the hemorrhage. Preclinical studies have identified multiple secondary injury mechanisms following IVH, and particularly the role of blood components (e.g. hemoglobin, iron, thrombin). This review, with an emphasis on pre-clinical IVH research, highlights therapeutic targets and treatments that may be of use in prevention, acute care, or repair of damage. Expert opinion: An IVH is a potentially devastating event. Progress has been made in elucidating injury mechanisms, but this has still to translate to the clinic. Some pathways involved in injury also have beneficial effects (coagulation cascade/inflammation). A greater understanding of the downstream pathways involved in those pathways may allow therapeutic development. Iron chelation (deferoxamine) is in clinical trial for intracerebral hemorrhage and preclinical data suggest it may be a potential treatment for IVH.

Clinical features and prognostic factors in patients with intraventricular hemorrhage caused by ruptured arteriovenous malformations

Intraventricular hemorrhage (IVH) was associated with poor outcomes in patients with intracerebral hemorrhage. IVH had a high incidence in patients with ruptured arteriovenous malformations (AVMs). In this study, we aimed to discuss the clinical features and prognostic factors of outcomes in the patients with AVM-related IVH.From January 2010 to January 2016, we collected the data of the patients with AVM-related IVH retrospectively. The data, including clinical and radiological parameters, were collected to evaluate the clinical features. Univariate and multivariate logistic regression analyses were used to identify the prognostic factors for clinical outcomes (hydrocephalus, 6-month outcomes measured by the modified Rankin scale) in our cohort.A total of 67 eligible patients were included and 19 patients (28%) only presented with IVH. Thirty-three patients (49%) presented hydrocephalus, and 12 patients (18%) presented brain ischemia. Nineteen patients (28%) had a poor outcome after 6 months. In multivariate logistic regression, subarachnoid hemorrhage (SAH) (P = .028) was associated with hydrocephalus and higher Graeb score (P = .080) tended to increase the risk of hydrocephalus. The high Glasgow coma scale (P = .010), large hematoma volume of parenchyma (P = .006), and high supplemented Spetzler-Martin (sup-SM) score (P = .041) were independent factors of the poor outcome.IVH was common in ruptured AVMs and increased the poor outcomes in patients with the ruptured AVMs. The AVM-related IVH patients had a high incidence of hydrocephalus, which was associated with brain ischemia and SAH. Patients with lower Glasgow coma scale, lower sup-SM score, and smaller parenchymal hematoma had better long-term outcomes.

Adult posthaemorrhagic hydrocephalus animal models

Posthaemorrhagic hydrocephalus (PHH) is often associated with high morbidity and mortality and serves as an important clinical predictor of poor outcomes after intracranial haemorrhage (ICH). We are lack of effective medical intervention methods to improve functional outcomes in patients with PHH because little is still known about the mechanisms of PHH pathogenesis. Animal models play a key role in the study of PHH. Developed a suitable animal model that will help us to be better to find preventative strategies and improve the prognosis of patients with PHH. The purpose of this review is to summarize the body of knowledge gained from animal studies.

Post-hemorrhagic hydrocephalus: Recent advances and new therapeutic insights

Post-hemorrhagic hydrocephalus (PHH), also referred to as progressive ventricular dilatation, is caused by disturbances in cerebrospinal fluid (CSF) flow or absorption following hemorrhage in the brain. As one of the most serious complications of neonatal/adult intraventricular hemorrhage (IVH), subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI), PHH is associated with increased morbidity and disability of these events. Common sequelae of PHH include neurocognitive impairment, motor dysfunction, and growth impairment. Non-surgical measures to reduce increased intracranial pressure (ICP) in PHH have shown little success and most patients will ultimately require surgical management, such as external ventricular drainage and shunting which mostly by inserting a CSF drainage shunt. Unfortunately, shunt complications are common and the optimum time for intervention is unclear. To date, there remains no comprehensive strategy for PHH management and it becomes imperative that to explore new therapeutic targets and methods for PHH. Over past decades, increasing evidence have indicated that hemorrhage-derived blood and subsequent metabolic products may play a key role in the development of IVH-, SAH- and TBI-associated PHH. Several intervention strategies have recently been evaluated and cross-referenced. In this review, we summarized and discussed the common aspects of hydrocephalus following IVH, SAH and TBI, relevant experimental animal models, clinical translation of in vivo experiments, and potential preventive and therapeutic targets for PHH.

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

OBJECT

External ventricular drainage (EVD) after intraventricular hemorrhage (IVH) without symptomatic hydrocephalus is controversial. The object of this study was to examine indicators or the timeframe for hydrocephalus in patients not immediately treated with EVD after IVH.

METHODS

Records from 2007 to 2014 were searched for "intraventricular hemorrhage" or "IVH." Inclusion criteria were IVH after intracerebral hemorrhage (ICH), trauma, tumor, or vascular anomalies. Exclusion criteria were IVH with more than minimal subarachnoid hemorrhage, catastrophic ICH, layering IVH only, or hydrocephalus treated immediately with EVD. IVH was measured with the modified Graeb Score (mGS). An mGS of 5 indicates a full ventricle with dilation. Statistics included chi-square, Student's t-test, and Mann-Whitney tests; receiver operating characteristics; and uni- and multivariate logistic regression.

RESULTS

One hundred five patients met the criteria; of these, 30 (28.6%) required EVD. Panventricular IVH was the most common pattern (n = 49, 46.7%), with 25 of these patients (51%) requiring EVD. The median mGS was 18 ± 5.4 (range 12-29) and 9 ± 4.5 (range 2-21) in the EVD and No-EVD groups, respectively (p < 0.001). Factors associated with EVD were radiological hydrocephalus at presentation, midline shift > 5 mm, Glasgow Coma Scale (GCS) score < 8, mGS > 13, third ventricle mGS = 5, and fourth ventricle mGS = 5. On multivariate analysis, GCS score < 8 [4.02 (range 1.13-14.84), p = 0.032], mGS > 13 [3.83 (range 1.02-14.89), p = 0.046], and fourth ventricle mGS = 5 [5.01 (range 1.26-22.78), p = 0.022] remained significant. Most patients treated with EVD (n = 25, 83.3%) required it soon after presentation [6.4 ± 3.3 (range 1.5-14) hrs]. The remaining 5 patients (16.7%) had a delayed EVD requirement [70.7 ± 22.7 (range 50-104.5) hrs].

CONCLUSIONS

In this study population, the risk for EVD was variable, but greater with mGS > 13, coma, and a dilated fourth ventricle. While the need for EVD occurs within the 1st day after IVH in most patients, a minority require EVD after 48 hours.

Spontaneous intracerebral and intraventricular hemorrhage: advances in minimally invasive surgery and thrombolytic evacuation, and lessons learned in recent trials

Optimal management of spontaneous intracerebral hemorrhage (ICH) remains one of the highly debated areas in the field of neurosurgery. Earlier studies comparing open surgical intervention with best medical management failed to show a clear benefit. More recent experience with minimally invasive techniques has shown greater promise. Well-designed phase II trials have confirmed the safety and preliminary treatment effect of thrombolytic aspiration and clearance of spontaneous ICH and associated intraventricular obstructive hemorrhage. Those trials are reviewed, including respective protocols and technical nuances, and lessons learned regarding patient selection, the concept of hemorrhage stabilization, optimization of the surgical procedure, and thrombolytic dosing decisions. These concepts have been incorporated in the design of ongoing definite phase III randomized trials (MISTIE and CLEAR) funded by the National Institutes of Health. These are presented including the role of surgical leadership in the training and monitoring of the surgical task and quality assurance. The impact of these techniques on neurosurgical practice is discussed.

Urokinase versus Alteplase for intraventricular hemorrhage fibrinolysis

Intraventricular hemorrhage (IVH) is the most severe form of stroke with intraventricular fibrinolysis (IVF) as a hopeful treatment. Urokinase (uPA) and tissue-type plasminogen activator (tPA) are used for IVF in Human. No clinical trial has evaluated the differential impact of these two fibrinolytics for IVF. Thus, we decided here to compare the use of these two fibrinolytics in a pre-clinical study. IVH was induced in rats by injection of collagenase type VII within the brain parenchyma followed by an IVF. Rats were randomized to receive uPA, tPA or saline within the ventricle, and cerebrospinal fluid was aspirated. Hematoma and ventricular volumes, brain water contents, inflammation and neurological deficits were measured at day three post-treatments. We also performed in vitro studies, in which neuronal cultures were subjected to an excitotoxic paradigm in the presence of either uPA or tPA. In the IVH model, we showed that although both uPA and tPA led to reduced ventricular volumes, only uPA significantly improved functional recovery. These results could be explained by the fact that uPA, in contrast of tPA, fails to promote inflammatory processes and neurotoxicity. Our study provides evidence supporting the use of uPA for fibrinolysis of IVH. A clinical trial could be warranted if tPA failed to improve outcomes in human IVH.

Single versus bilateral external ventricular drainage for intraventricular fibrinolysis using urokinase in severe ventricular haemorrhage

BACKGROUND

Intraventricular fibrinolysis (IVF) through bilateral external ventricular drains (EVD) may provide better access of the thrombolytic agent to the intraventricular clot, potentially leading to faster clot clearance.

OBJECTIVE

To compare the feasibility and safety between single and bilateral EVD groups.

METHODS

Patients with spontaneous intraventricular haemorrhage (IVH) (Graeb score ≥ 5) were treated with IVF. The selection for placement of one or two EVDs was randomized. The average daily CSF drainage volume, the indwelling EVD time, the time for monitoring in intensive care unit (ICU), intracranial re-haemorrhage and intracranial infection, Glasgow coma score (GCS), Graeb score and the reserved IVH volume have been analysed for patients with one (group I, n = 22) or two EVDs (group II, n = 25).

RESULTS

Significant difference was found in the average daily CSF drainage volume between the two groups (85.2 (SD = 13.7) vs. 108.5 (15.9) ml). No difference was found in the indwelling EVD time, the time for monitoring in the ICU. Through repeated measurements of the variance analysis, the test for a difference in IVH volume over time was statistically significant (F = 466.981, p = 0.000) and the test for the interaction between treatment and time was also significant (F = 5.033, p = 0.002), indicating that the IVH volume decreased over time in both groups, with a sharper decrease in Group II. Intracranial re-haemorrhage and infection was not found in this study.

CONCLUSION

The results provide some evidence to support the use of bilateral EVDs for IVF in patients with severe IVH.

A novel combined model of intracerebral and intraventricular hemorrhage using autologous blood-injection in rats

Intracerebral hemorrhage (ICH) is the least treatable form of stroke and is associated with the worst prognosis. In up to 40% of cases, ICH is further complicated by intraventricular hemorrhage (IVH), which predisposes to hydrocephalus, and increases case-mortality to 80%. However, IVH is not present in widely used preclinical models of ICH. Here, we characterize a novel rat model of combined ICH and IVH. Rats were injected with different volumes of autologous whole blood into the right deep basal ganglia region (100μL, 150μL, 200μL, and 250μL, n=10 per group). MRI was performed immediately, and at 24, 48, 72h, and 1week after blood injection, along with neurological evaluations. Injected blood volume reliably correlated with blood volumes measured from MRI obtained after blood injection. Brain edema was most prominent in the ⩾200μL groups, peaking at 48h in all groups, being statistically different between the ⩾200μL and <200μL groups at all-time points. Presence of hydrocephalus was detected in most of the animals, most clearly in the 200μL and 250μL groups, both being statistically different from the 100μL group at all-time points, with tendency to worsen during the whole follow-up period. Most deteriorating neurological and behavioral outcomes as well as the highest mortality rates were detected in groups injected with 200μL and 250μL of autologous blood, 40% and 70%, respectively. These volumes were most similar to the clinical scenario of combined ICH and IVH, demonstrating that this novel rat model is a promising starting point for future ICH+IVH research.

Progress in translational research on intracerebral hemorrhage: is there an end in sight?

Intracerebral hemorrhage (ICH) is a common and often fatal stroke subtype for which specific therapies and treatments remain elusive. To address this, many recent experimental and translational studies of ICH have been conducted, and these have led to several ongoing clinical trials. This review focuses on the progress of translational studies of ICH including those of the underlying causes and natural history of ICH, animal models of the condition, and effects of ICH on the immune and cardiac systems, among others. Current and potential clinical trials also are discussed for both ICH alone and with intraventricular extension.

Thrombolytic evacuation of intracerebral and intraventricular hemorrhage

Intracranial hemorrhage (ICH) accounts for 10-15 % of all strokes, however it causes 30-50 % of stroke related mortality, disability and cost. The prevalence increases with age with only two cases/100,000/year for age less than 40 years to almost 350 cases/100,000/year for age more than 80 years. Several trials of open surgical evacuation of ICH have failed to show clear benefit over medical management. However, some small trials of minimal invasive hematoma evacuation in combination with thrombolytics have shown encouraging results. Based on these findings larger clinical trials are being undertaken to optimize and define therapeutic benefit of minimally invasive surgery in combination with thrombolytic clearance of hematoma. In this article we will review some of the background of minimally invasive surgery and the use of thrombolytics in the setting of ICH and intraventricular hemorrhage (IVH) and will highlight the early findings of MISTIE and CLEAR trials for these two entities respectively.

Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema

BACKGROUND AND PURPOSE

Perihematomal edema (PHE) can worsen outcomes after intracerebral hemorrhage (ICH). Reports suggest that blood degradation products lead to PHE. We hypothesized that hematoma evacuation will reduce PHE volume and that treatment with recombinant tissue-type plasminogen activator (rt-PA) will not exacerbate it.

METHODS

Minimally invasive surgery and rt-PA in ICH evacuation (MISTIE) phase II tested safety and efficacy of hematoma evacuation after ICH. We conducted a semiautomated, computerized volumetric analysis on computed tomography to assess impact of hematoma removal on PHE and effects of rt-PA on PHE. Volumetric analyses were performed on baseline stability and end of treatment scans.

RESULTS

Seventy-nine surgical and 39 medical patients from minimally invasive surgery and rt-PA in ICH evacuation phase II (MISTIE II) were analyzed. Mean hematoma volume at end of treatment was 19.6±14.5 cm(3) for the surgical cohort and 40.7±13.9 cm(3) for the medical cohort (P<0.001). Edema volume at end of treatment was lower for the surgical cohort: 27.7±13.3 cm(3) than medical cohort: 41.7±14.6 cm(3) (P<0.001). Graded effect of clot removal on PHE was observed when patients with >65%, 20% to 65%, and <20% ICH removed were analyzed (P<0.001). Positive correlation between PHE reduction and percent of ICH removed was identified (ρ=0.658; P<0.001). In the surgical cohort, 69 patients underwent surgical aspiration and rt-PA, whereas 10 underwent surgical aspiration only. Both cohorts achieved similar clot reduction: surgical aspiration and rt-PA, 18.9±14.5 cm(3); and surgical aspiration only, 24.5±14.0 cm(3) (P=0.26). Edema at end of treatment in surgical aspiration and rt-PA was 28.1±13.8 cm(3) and 24.4±8.6 cm(3) in surgical aspiration only (P=0.41).

CONCLUSIONS

Hematoma evacuation is associated with significant reduction in PHE. Furthermore, PHE does not seem to be exacerbated by rt-PA, making such neurotoxic effects unlikely when the drug is delivered to intracranial clot.

Drainage efficiency with dual versus single catheters in severe intraventricular hemorrhage

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.

Management of non-traumatic intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is defined as the eruption of blood in the cerebral ventricular system and is mostly secondary to spontaneous intracerebral hemorrhage and aneurysmal and arteriovenous malformation rupture. IVH is a proven risk factor of increased mortality and poor functional outcome. Its seriousness is correlated not only with the amount of blood but also with the involvement of the third and fourth ventricles. There are four mechanisms that explain the pathophysiology of this event: acute obstructive hydrocephalus, the mass effect exerted by the blood clot, the toxicity of blood-breaking products on the adjacent brain parenchyma, and, lastly, the development of a chronic hydrocephalus. It is thus obvious that the clearance of blood from the ventricles should be a therapeutic goal. In cases of acute hydrocephalus, external ventricular drainage is a mandatory step, but proven often insufficient. The concomitant use of intraventricular fibrinolytics such as recombinant tissue plasminogen activator or urokinase seems to be beneficial at least in the context of spontaneous intracerebral hemorrhage, in which their use is now accepted but not yet validated by a randomized trial. Given the potential neurotoxicity of these agents, further research is needed in order to identify the best treatment for intraventricular fibrinolysis (IVF). The endoscopic retrieval of intraventricular blood was also described recently and seems to be as efficient as IVF, but its use is limited to specialized centers. IVH represents a therapeutic challenge for neurosurgeons, neurologists, and intensivists. Thus, a better understanding of this dramatic event will help in better tailoring the treatment strategies.

A Brain Parenchyma Model-Based Segmentation of Intraventricular and Intracerebral Haemorrhage in CT Scans

Accurate quantification of haemorrhage volume in a computed tomography (CT) scan is critical in the management and treatment planning of intraventricular (IVH) and intracerebral haemorrhage (ICH). Manual and semi-automatic methods are laborious and time-consuming limiting their applicability to small data sets. In clinical trials measurements are done at different locations and on a large number of data; an accurate, consistent and automatic method is preferred. A fast and efficient method based on texture energy for identification and segmentation of hemorrhagic regions in the CT scans is proposed. The data set for the study was obtained from CLEAR-IVH clinical trial phase III (41 patients’ 201 sequential CT scans from ten different hospitals, slice thickness 2.5–10 mm and from different scanners). The DICOM data were windowed, skull stripped, convolved with textural energy masks and segmented using a hybrid method (a combination of thresholding and fuzzy c-means). Artifacts were removed by statistical analysis and morphological processing. Segmentation results were compared with the ground truth. Descriptive statistics, Dice statistical index (DSI), Bland-Altman and mean difference analysis were carried out. The median sensitivity, specificity and DSI for slice identification and haemorrhage segmentation were 86.25%, 100%, 0.9254 and 84.90%, 99.94%, 0.8710, respectively. The algorithm takes about one minute to process a scan in MATLAB®. A hybrid method-based volumetry of haemorrhage in CT is reliable, observer independent, efficient, reduces the time and labour. It also generates quantitative data that is important for precise therapeutic decision-making.

External ventricular drainage for intraventricular hemorrhage

Hemorrhagic stroke accounts for only 10% to 15% of all strokes; however, it is associated with devastating outcomes. Extension of intracranial hemorrhage (ICH) into the ventricles or intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome. In most circumstances the increased intracranial pressure and acute hydrocephalus caused by ICH is managed by placement of an external ventricular drain (EVD). We present a systematic review of the literature on the topic of EVD in the setting of IVH hemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.

Low-dose recombinant tissue-type plasminogen activator enhances clot resolution in brain hemorrhage: the intraventricular hemorrhage thrombolysis trial

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.

Management of intraventricular hemorrhage

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.

Management of acute intracranial and intraventricular hemorrhage

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.

Brain interstitial fluid TNF-alpha after subarachnoid hemorrhage

OBJECTIVE

TNF-alpha is an inflammatory cytokine that plays a central role in promoting the cascade of events leading to an inflammatory response. Recent studies have suggested that TNF-alpha may play a key role in the formation and rupture of cerebral aneurysms, and that the underlying cerebral inflammatory response is a major determinate of outcome following subrarachnoid hemorrhage (SAH).

METHODS

We studied 14 comatose SAH patients who underwent multimodality neuromonitoring with intracranial pressure (ICP) and cerebral microdialysis as part of their clinical care. Continuous physiological variables were time-locked every 8h and recorded at the same point that brain interstitial fluid TNF-alpha was measured in brain microdialysis samples. Significant associations were determined using generalized estimation equations.

RESULTS

Each patient had a mean of 9 brain tissue TNF-alpha measurements obtained over an average of 72h of monitoring. TNF-alpha levels rose progressively over time. Predictors of elevated brain interstitial TNF-alpha included higher brain interstitial fluid glucose levels (beta=0.066, p<0.02), intraventricular hemorrhage (beta=0.085, p<0.021), and aneurysm size >6mm (beta=0.14, p<0.001). There was no relationship between TNF-alpha levels and the burden of cisternal SAH; concurrent measurements of serum glucose, or lactate-pyruvate ratio.

INTERPRETATION

Brain interstitial TNF-alpha levels are elevated after SAH, and are associated with large aneurysm size, the burden of intraventricular blood, and elevation brain interstitial glucose levels.

Keeping CSF valve function with urokinase in children with intra-ventricular haemorrhage and CSF shunts

BACKGROUND

Intra-ventricular haemorrhage (IVH) can occur spontaneously or during the surgical revision of ventricular cerebrospinal fluid (CSF) shunts.

AIM

The aim of the study was to report the safety and efficacy of an original method for treatment of IVH that may occur at the time of valve revision aimed at maintaining the function of previously implanted CSF shunts.

PATIENTS AND METHODS

We reviewed the medical records of six patients who experienced an IVH in the presence of a previously placed ventriculoperitoneal (VP) shunt. Five of the haemorrhages occurred during ventricular catheter replacement and the remaining one in a child given a VP shunt who sustained a spontaneous intra-cerebral haemorrhage. We inserted an external ventricular drainage without removing the original shunt. Urokinase was administered via the ventricular drain during several days until blood clearance in the CSF. Disappearance of the ventricular clots was checked by a cranial computerised tomography scan, while CSF shunt function was verified by the children's evolution and/or by a reservoir tap.

RESULTS

Follow-up evaluation of the six patients demonstrated that the existing VP shunts were functioning appropriately and that the treatment was safe.

CONCLUSIONS

Patients with IVH complicating ventricular catheter replacement and patients with spontaneous bleeding who harbour a VP shunt can be treated by intra-ventricular urokinase to avoid the removal of the initial shunt. The technique has proven to be safe and utilises the ventricular drain placed for the acute management of the IVH. Shunt replacement will always be possible in case of failure of the technique we are reporting.

[Treatment of intraventricular hemorrhage and hydrocephalus]

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.

Intraventricular hemorrhage: severity factor and treatment target in spontaneous intracerebral hemorrhage

BACKGROUND AND PURPOSE

This review focuses on the emerging principles of intracerebral hemorrhage (ICH) management, emphasizing the natural history and treatment of intraventricular hemorrhage. The translational and clinical findings from recent randomized clinical trials are defined and discussed. Summary of Review- Brain hemorrhage is the most severe of the major stroke subtypes. Extension of the hemorrhage into the ventricles (a 40% occurrence) can happen early or late in the sequence of events. Epidemiological data demonstrate the amount of blood in the ventricles relates directly to the degree of injury and likelihood of survival. Secondary tissue injury processes related to intraventricular bleeding can be reversed by removal of clot in animals. Specific benefits of removal include limitation of inflammation, edema, and cell death, as well as restoration of cerebral spinal fluid flow, intracranial pressure homeostasis, improved consciousness, and shortening of intensive care unit stay. Limited clinical knowledge exists about the benefits of intraventricular hemorrhage (IVH) removal in humans, because organized attempts to remove blood have not been undertaken in large clinical trials on a generalized scale. New tools to evaluate the volume and location of IVH and to test the benefits/risks of removal have been used in the clinical domain. Initial efforts are encouraging that increased survival and functional improvement can be achieved. Little controversy exists regarding the need to scientifically investigate treatment of this severity factor.

CONCLUSIONS

Animal models demonstrate clot removal can improve the acute and long-term consequences of intraventricular extension from intracerebral hemorrhage by using minimally invasive techniques coupled to recombinant tissue plasminogen activator-mediated clot lysis. The most recent human clinical trials show that severity of initial injury and the long-term consequences of blood extending into the ventricles are clearly related to the amount of bleeding into the ventricular system. The failure of the last 2 pivotal brain hemorrhage randomized control trials may well relate to the consequences of intraventricular bleeding. Small proof of concept studies, meta-analyses, and preliminary pharmacokinetics studies support the idea of positive shifts in mortality and morbidity, if this 1 critical disease severity factor, IVH, is properly addressed. Understanding clinical methods for the removal of IVH is required if survival and long-term functional outcome of brain hemorrhage is to improve worldwide.

A neonatal piglet model of intraventricular hemorrhage and posthemorrhagic ventricular dilation

OBJECT

The combination of intraventricular hemorrhage (IVH) and posthemorrhagic ventricular dilation (PHVD) remains an important cause of disability in children surviving prematurity. Currently, there is no clear agreement on the management of neonatal IVH, apart from the eventual insertion of a shunt to control PHVD. Cerebrospinal fluid (CSF) shunts are associated with a relatively high complication rate in this population. The development of new treatment options requires greater understanding of the pathophysiological mechanisms of IVH and PHVD, as well as an opportunity to monitor closely their effects on the immature brain. The authors have developed a neonatal large animal model of IVH with long-term survival, allowing the full development of PHVD.

METHODS

Fourteen piglets that were 3 to 24 hours old were randomized to receive slow injections of autologous blood, autologous blood with elevated hematocrit, or artificial CSF after induction of general anesthesia. A fourth group served as controls. All animals underwent surgery to form an artificial fontanelle at the bregma. Physiological parameters, including intracranial pressure and electroencephalography, were monitored during injection.

RESULTS

Serial cranial ultrasonography studies performed during the 23- to 44-day survival period demonstrated progressive ventricular dilation in the animals injected with blood. Ventricular volumes, measured with image analysis software, confirmed the highest dilation after injection of blood with an elevated hematocrit. Histological evaluation showed fibrosis in the basal subarachnoid space of hydrocephalic piglets.

CONCLUSIONS

This piglet model closely replicates human neonatal IVH and PHVD. It allows detailed physiological and ultrasonographic monitoring over a prolonged survival period. It is suitable for evaluation of noninvasive as well as surgical options in the management of IVH and PHVD.

Fibrinolytic therapy in spontaneous intraventricular haemorrhage: efficacy and safety of the treatment

Intraventricular haemorrhage (IVH) is associated with a poor outcome. Simple external ventricular drainage has not modified the high morbidity and mortality of these patients. Our objective was to review our experience using intraventricular urokinase (UK) in treating patients with moderate to severe IVH. Prospective analysis of medical records of 14 patients diagnosed with spontaneous IVH who received ventriculostomy and intraventricular infusion of UK from January 2002 to December 2005. Patients with the following characteristics were included: 18-70 years of age, GCS between 5 and 14, and moderate to severe IVH (Graeb > or = 6) without simultaneous intraparenchymal haematoma > 30 ml. The final results were compared to historic control group (14 patients) treated between January 1999 to December 2001 with ventriculostomy alone. All 28 patients accomplished the inclusion criteria. Patient age, initial GCS and Graeb classification of IVH were similar in the two groups of treatment. There was higher ventriculostomy obstruction rate in the non-UK group (33.3 vs. 0%; p > 0.05), a higher rate of intracranial hypertension in the non-UK group (66.6 vs. 16.6%; p = 0.036) and a lower mortality rate in the UK group (25 vs. 58.3%, p > 0.05). There was no rebleeding associated with UK treatment. Intraventricular UK appears to be a safe treatment. It is effective in the prevention of catheter blockage, speeding the clearance of IVH, and it is associated with lower rate of intracranial hypertension and death.

Thrombolytics in intraventricular hemorrhage

Intraventricular hemorrhage (IVH) may occur as an isolated event from primary ventricular bleeding or as a complication of brain hemorrhage from another etiology. It is associated with high mortality and morbidity. Recent translational and clinical studies demonstrate that thrombolytic drugs administered intraventricularly through an external ventricular drain to lyse an IVH clot are safe and may reduce morbidity and mortality. The ongoing, prospective, randomized clinical trial known as Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR IVH) offers new hope for patients with this devastating disease. Preliminary data show marked reduction in time to clot lysis as well as a potential reduction in mortality associated with IVH lysis. A large, phase III, randomized prospective trial to ascertain the true clinical efficacy of this treatment is currently in the planning stages. A review of the use of thrombolytics for treatment of IVH related to other secondary causes is also provided.

Treatment of sympathomimetic induced intraventricular hemorrhage with intraventricular urokinase

Intraventricular hemorrhage (IVH) occurred in a 32-year-old man following the use of both ephedrine and pseudoephedrine. Cerebral angiography and transcranial Doppler studies showed changes suggestive of vasculitis. We describe the management and investigations of a unique case of IVH. This patient was treated with ventriculostomy and intraventricular urokinase (UK). A favorable outcome was obtained with independent function at 10 weeks post hemorrhage. The use of intraventricular thrombolysis for drug-induced IVH has not previously been reported, although it has been shown to be a safe and potentially beneficial intervention.

The use of intraventricular thrombolytics in intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is associated with a high mortality and morbidity. Patients with this disorder may now be offered the possibility of treatment. This treatment comes in the form of intraventricular thrombolytics. At present a large randomized trial is testing the efficacy of intraventricular rt-PA in IVH in the setting of intracranial hemorrhage (ICH) . Preliminary data suggests that it may be successful in patients with IVH in this setting. This trial is the accumulation of animal and human trials completed over the last 20 years.

Intraventricular Hemorrhage after Aneurysmal Subarachnoid Hemorrhage: Pilot Study of Treatment with Intraventricular Tissue Plasminogen Activator

OBJECTIVE

Intraventricular (IVen) hemorrhage is considered a predictor of poor outcome after subarachnoid hemorrhage (SAH). This prospective study examines the feasibility and outcome of administration of IVen tissue plasminogen activator (tPA) after aneurysmal SAH.

METHODS

Ten patients with SAH who received IVen tPA after the aneurysm had been secured were compared with 10 age-, sex-, and Glasgow Coma Scale score-matched control patients. The primary end point was third and fourth ventricle clot resolution. IVen blood was quantified by use of the Graeb and Le Roux scales on admission and at an additional time (equal or longer for the control group) after the injection was terminated.

RESULTS

Six men and four women with a mean age of 52 years in each group were evaluated. On average, 3.5 mg tPA was injected 68 +/- 51 hours after admission without ensuing complications. Although the treated group had significantly more IVen blood on admission than control subjects (mean Le Roux scale +/- standard deviation, 11 +/- 3 versus 7.6 +/- 4.2, P = 0.055, and mean Graeb scale +/- standard deviation, 8.5 +/- 2.3 in tPA versus 5.3 +/- 3, P < 0.02), it also had a significant decrease in the amount of IVen blood (mean Le Roux and Graeb scale decrease +/- standard deviation, 6.7 +/- 3.3 and 4.8 +/- 2 in tPA patients versus 0.9 +/- 3.2 and 0.5 +/- 2.6 in control subjects, P = 0.002). The tPA group had a non-statistically significantly shorter length of stay, decreased mortality, and better Glasgow Outcome Scale and modified Rankin Scale scores at discharge. Treated survivors showed a decreased need for shunt placement (2 [22%] of 9 patients versus 5 [83%] of 6 control subjects, P = 0.04).

CONCLUSION

This pilot study shows that IVen tPA administration is feasible without complications after SAH and may be associated with better outcomes. These results warrant a randomized clinical trial.

Cohort study of intraventricular thrombolysis with recombinant tissue plasminogen activator for aneurysmal intraventricular hemorrhage

OBJECTIVE

Thrombolytic agents have been administered through external ventricular drains to treat intraventricular hemorrhage, the goals being to accelerate clot clearance, prevent catheter obstruction, and help control intracranial pressure. We compared these variables in a group of aneurysm patients treated by one surgeon who routinely used intraventricular recombinant tissue plasminogen activator (rt-PA) for obstructive hematocephalus with those in a group of similar patients treated by other surgeons who did not.

METHODS

Patients included in this analysis were those with repaired cerebral aneurysms causing hemorrhage into at least three ventricles with ventriculomegaly requiring external ventricular drainage. The ventricular system was considered "opened" when all ventricles were patent and reduced in size on computed tomographic scans. Those treated with rt-PA received 4 mg/d through a ventricular drain until ventricular opening.

RESULTS

The mean number of days to ventricular opening was 3.9 (standard deviation [SD], 1.0) for the 21 patients treated with rt-PA and 7.1 (SD, 3.7) for the 9 who were not (P = 0.001), and the mean intracranial pressure (mm Hg) 24 hours after treatment with rt-PA was 10.4 (SD, 6.1) compared with 14.1 (SD, 5.9) during the same interval for the group that did not receive rt-PA (P = 0.13). Ventricular catheter replacement was required in 1 rt-PA patient (for a misplaced catheter, before rt-PA treatment) and 3 patients who did not receive rt-PA (all for catheter obstructions with blood clot) (P = 0.07), and ventriculoperitoneal shunts were placed in 4 rt-PA patients and 3 patients who did not receive rt-PA (P = 0.4).

CONCLUSION

Intraventricular thrombolysis with rt-PA seems to assist in the acute management of patients with large aneurysmal intraventricular hemorrhages, speeding clearance of aneurysmal intraventricular hemorrhage, normalizing intracranial pressure, and reducing ventricular catheter obstruction. A randomized trial is needed to confirm these findings, establish treatment safety, and determine whether treatment affects outcome.

The pathogenesis of neonatal post-hemorrhagic hydrocephalus

Hydrocephalus after intraventricular hemorrhage (IVH) has emerged as a major complication of preterm birth and is especially problematic to treat. The hydrocephalus is usually ascribed to fibrosing arachnoiditis, meningeal fibrosis and subependymal gliosis, which impair flow and resorption of cerebrospinal fluid (CSF). Recent experimental studies have suggested that acute parenchymal compression and ischemic damage, and increased parenchymal and perivascular deposition of extracellular matrix proteins--probably due at least partly to upregulation of transforming growth factor-beta (TGF-beta)--are further important contributors to the development of the hydrocephalus. IVH is associated with damage to periventricular white matter and the damage is exacerbated by the development of hydrocephalus; combinations of pressure, distortion, ischaemia, inflammation, and free radical-mediated injury are probably responsible. The damage to white matter accounts for the high frequency of cerebral palsy in this group of infants. The identification of mechanisms and mediators of hydrocephalus and white matter damage is leading to the development of new treatments to prevent permanent hydrocephalus and its neurological complications, and to avoid shunt dependence.

Fibrinolytic therapy for intraventricular hemorrhage in adults

BACKGROUND

Spontaneous or secondary intraventricular hemorrhage is a marker of poor prognosis for hemorrhagic stroke. It can cause hydrocephalus and require ventricular shunt placement, result in permanent neurological deficits or death. Fibrinolytic agents injected into the ventricular system could dissolve blood clots, increase the clearance of blood from the ventricles and hence improve outcome.

OBJECTIVES

To assess the clinical efficacy and safety of thrombolytic agents administered intraventricularly in the management of intraventricular hemorrhage in adults.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched February 2002). In addition, we searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, Current Contents, and International Pharmacy Abstracts to 2001. We handsearched several neurosurgery journals and the references list of articles identified.

SELECTION CRITERIA

Randomised unconfounded studies comparing intraventricular fibrinolytic therapy to placebo or open control for the management of intraventricular hemorrhage in adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed all identified trials. Clinically significant information related to patient population, efficacy and safety were extracted and summarized.

MAIN RESULTS

A total of ten studies were identified by our search strategy. Eight of them were excluded because of case series designs or retrospective control group. One quasi-randomised trial used alternate allocation and was excluded. Only one report met the review criteria for randomization. The randomised trial reported good outcome but has important design flaws resulting in a biased control group and therefore was excluded.

REVIEWER'S CONCLUSIONS

There is anecdotal evidence suggesting that the intraventricular administration of fibrinolytic agents in intraventricular hemorrhage maybe of therapeutic value and safe. Thus far, there are no randomised trials of sufficient size and quality to evaluate the safety and efficacy of this treatment modality.

Blood clot resolution in human cerebrospinal fluid: evidence of first-order kinetics

OBJECTIVE

To determine the kinetics of blood clot resolution in human cerebrospinal fluid.

METHODS

Computed tomographic scans of 17 adult patients with intraventricular hemorrhages were analyzed. Intraventricular clot volume was determined and analyzed over time to determine both a standardized percentage rate and an absolute rate of clot resolution. Results were analyzed by use of regression for cross sectional time-series data. To determine the kinetics of intraventricular clot resolution, the effect of the clot volume on the percentage rate of clot resolution, clot half-life, and absolute rate of clot resolution was analyzed. The potential effect of age, sex, type of hemorrhage, and treatment with external ventricular drainage on the percentage rate of clot resolution was assessed.

RESULTS

The percentage rate of clot resolution was 10.8% per day (95% confidence interval, 9.05-12.61 %), and it was independent of initial clot volume, age, sex, type of underlying hemorrhage, and use of external ventricular drainage. The absolute rate of clot resolution varied directly with the maximal clot volume (R2 = 0.88; P < 0.001). The percentage clot resolution data are consistent with events during the first 24 to 48 hours that antagonize clot resolution.

CONCLUSION

These findings demonstrate that intraventricular blood clot resolution in patients with intraventricular hemorrhage follows first-order kinetics. The thrombolytic enzyme system responsible for intraventricular clot resolution seems to be saturated at 24 to 48 hours after the initial hemorrhage.

Treatment of intraventricular hemorrhage with urokinase : effects on 30-Day survival

BACKGROUND AND PURPOSE

Intraventricular hemorrhage (IVH) remains associated with high morbidity and mortality. Therapy with external ventricular drainage alone has not modified outcome in these patients.

METHODS

Twelve pilot IVH patients who required external ventricular drainage were prospectively treated with intraventricular urokinase followed by the randomized, double-blinded allocation of 8 patients to either treatment or placebo. Observed 30-day mortality was compared with predicted 30-day mortality obtained by use of a previously validated method.

RESULTS

Twenty patients were enrolled; admission Glasgow Coma Scale score in 11 patients was </=8; 10 patients had pulse pressure <85 mm Hg. Mean+/-SD ICH volume in 16 patients was 6.21+/-7.53 cm(3) (range 0 to 23.88 cm(3)), and mean+/-SD intraventricular hematoma volume was 44.26+/-31.65 cm(3) (range 1.31 to 100.36 cm(3)). Four patients (20%) died within 30 days. Predicted mortality for these 20 patients was 68.42% (range 3% to 100%). Probability of observing </=4 deaths among 20 patients under a 68.42% expected mortality is 0.000012.

CONCLUSIONS

Intraventricular urokinase may significantly improve 30-day survival in IVH patients. On the basis of current evidence, a double-blinded, placebo-controlled, multicenter study that uses thrombolysis to treat IVH has received funding and began January 1, 2000.