Tag: Intraventricular hemorrhage

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Continuous irrigation with thrombolytics for intraventricular hemorrhage: case–control study

Neurosurgical Review (2024) 47:40

Intraventricular hemorrhage (IVH) is a complication of a spontaneous intracerebral hemorrhage. Standard treatment is with external ventricular drain (EVD). Intraventricular thrombolysis may improve mortality but does not improve functional outcomes. We present our initial experience with a novel irrigating EVD (IRRAflow) that automates continuous irrigation with thrombolysis.

Single-center case–control study including patients with IVH treated with EVD compared to IRRAflow. We compared standard demographics, treatment, and outcome parameters between groups. We developed a brain phantom injected with a human clot and assessed clot clearance using EVD/IRRAflow approaches with CT imaging.

Twenty-one patients were treated with standard EVD and 9 patients with IRRAflow. Demographics were similar between groups. Thirty-three percent of patients with EVD also had at least one dose of t-PA and 89% of patients with IRRAflow received irrigation with t-PA (p = 0.01). Mean drain days were 8.8 for EVD versus 4.1 for IRRAflow (p = 0.02). Days-toclearance of ventricular outflow was 5.8 for EVD versus 2.5 for IRRAflow (p = 0.02). Overall clearance was not different. Thirty-seven percent of EVD patients achieved good outcome (mRS ≥ 3) at 90 days versus 86% of IRRAflow patients (p = 0.03). Assessing only t-PA, reduction in mean days-to-clearance (p = 0.0004) and ICU days (p = 0.04) was observed. In the benchtop model, the clot treated with IRRAflow and t-PA showed a significant reduction of volume compared to control.

Irrigation with IRRAflow and t-PA is feasible and safe for patients with IVH. Improving clot clearance with IRRAflow may result in improved clinical outcomes and should be incorporated into randomized trials.

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Management of severe intraoperative hemorrhage during intraventricular neuroendoscopic procedures: the dry field technique

Acta Neurochirurgica (2022) 164:2551–2557

Neuroendoscopic procedures inside the ventricular system always bear the risk for an unexpected intraoperative hemorrhage with potentially devastating consequences. The authors present here their experience, and a stage-to-stage guide for the endoscopic management of intraoperative hemorrhages.

Methods A step-by-step guide for the management to gain control of and stop the bleeding is described including a grading system. More advanced techniques are presented in cases examples.

Conclusion Most of intraoperative hemorrhages can be controlled by constant irrigation and coagulation. More advanced techniques can be applied quickly and easily to ensure control of the hemorrhages and avoid the need for a microsurgical conversion.

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Endoscopic clipping of intraventricular aneurysms using the “wet-field” technique

J Neurosurg 131:104–108, 2019

Intraventricular hemorrhage and intracerebral aneurysms are relatively frequent complications associated with moy- amoya disease. Prevention of aneurysm rerupture is important because it significantly decreases the morbidity and mortality rates. Aneurysms arising distal to collateral flow are sometimes observed in patients with intraventricular hem- orrhage; however, the treatment of these aneurysms remains challenging because of their deep-seated location in the brain and accompanying narrow surgical corridor.

The authors describe a neuroendoscopic aneurysm clipping technique performed in 2 cases using a small-diameter tubular retractor for intraventricular aneurysms of the distal lateral posterior choroidal artery. In this technique, the surgical field was continuously irrigated with artificial CSF to keep the ventricle size intact, and aneurysm clipping was performed through a tubular retractor that was introduced with neuronavigational guidance. The patients’ postoperative courses were uneventful, and CT angiography revealed complete clipping of the aneurysms and patent parent arteries.

Endoscopic clipping using a tubular retractor is an effective and less invasive alternative for treating intraventricular aneurysms. The wet-field endoscopic technique is performed in an aqueous field and maintains an intact ventricle size, allowing for a clear surgical view and a wider, enhanced surgical field.

 

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Spontaneous Intracerebral and Intraventricular Hemorrhage: Advances in Minimally Invasive Surgery and Thrombolytic Evacuation, and Lessons Learned in Recent Trials

Spontaneous_Intracerebral_and_Intraventricular

Neurosurgery 74:S142–S150, 2014

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.

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Ventricular Catheter Location and the Clearance of Intraventricular Hemorrhage

Neurosurgery 70:1258–1264, 2012 DOI: 10.1227/NEU.0b013e31823f6571

There is no consensus regarding optimal position of an external ventricular drain (EVD) with regard to clearance of intraventricular hemorrhage (IVH).

OBJECTIVE: To assess the hypothesis that EVD laterality may influence the clearance of blood from the ventricular system with and without administration of thrombolytic agent.

METHODS: The EVD location was assessed in 100 patients in 2 Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR IVH) phase II trials assessing the safety and dose optimization of thrombolysis through the EVD to accelerate the clearance of obstructive IVH. Laterality of catheter was correlated with clearance rates.

RESULTS: Clearance of IVH over the first 3 days was significantly greater when thrombolytic compared with placebo was administered regardless of catheter laterality (P , .005; 95% confidence interval, 214.0 to 24.14 for contralateral EVD and 224.7 to 25.44 for ipsilateral EVD). When thrombolytic was administered, there was a trend toward more rapid clearance of total IVH through an EVD placed on the side of dominant intraventricular blood compared with an EVD on the side with less blood (P = .09; 95% confidence interval, 29.62 to 0.69). This was not true when placebo was administered. Clearance of third and fourth ventricular blood was unrelated to EVD laterality.

CONCLUSION: It is possible that placement of EVD may be optimized to enhance the clearance of total IVH if lytic agents are used. Catheters on either side can clear the third and fourth ventricles with equal efficiency.

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Minimally invasive treatment for intracerebral hemorrhage

Neurosurg Focus 32 (4):E3, 2012. http://thejns.org/doi/abs/10.3171/2012.1.FOCUS11362

Spontaneous intracerebral hemorrhage is a serious public health problem and is fatal in 30%–50% of all occurrences. The role of open surgical management of supratentorial intracerebral hemorrhage is still unresolved. A recent consensus conference sponsored by the National Institutes of Health suggests that minimally invasive techniques to evacuate clots appear to be a promising area and warrant further investigation. In this paper the authors review past, current, and potential future methods of treating intraparenchymal hemorrhages with minimally invasive techniques and review new data regarding the role of stereotactically placed catheters and thrombolytics.

A minimally invasive approach to evacuate ICH has been well documented to be a safe practice. Thus far, the CLEAR and MISTIE studies have supported this assertion. An increased rate of clot lysis could potentially be achieved with a combination of mechanical and pharmaceutical approaches. However, more extensive studies need to be conducted to determine whether the additional mechanical effects via ultrasound further yield beneficial long-term outcome versus pharmacological lysis alone. Currently, catheters are being redesigned for this purpose and will be evaluated in additional future clinical trials.

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Minimally invasive evacuation of spontaneous intracerebral hemorrhage using sonothrombolysis

J Neurosurg 115:592–601, 2011. DOI: 10.3171/2011.5.JNS10505

Catheter-based evacuation is a novel surgical approach for the treatment of brain hemorrhage. The object of this study was to evaluate the safety and efficacy of ultrasound in combination with recombinant tissue plasminogen activator (rt-PA) delivered through a microcatheter directly into spontaneous intraventricular (IVH) or intracerebral (ICH) hemorrhage in humans.

Methods. Thirty-three patients presenting to the Swedish Medical Center in Seattle, Washington, with ICH and IVH were screened between November 21, 2008, and July 13, 2009, for entry into this study. Entry criteria included the spontaneous onset of intracranial hemorrhage ≥ 25 ml and/or IVH producing ventricular obstruction. Nine patients (6 males and 3 females, with an average age of 63 years [range 38–83 years]) who met the entry criteria consented to participate and were entered into the trial. A ventricular drainage catheter and an ultrasound microcatheter were stereotactically delivered together, directly into the IVH or ICH. Recombinant tissue plasminogen activator and 24 hours of continuous ultrasound were delivered to the clot. Gravity drainage was performed. In patients with IVHs, 3 mg of rt-PA was injected; in patients with intraparenchymal hemorrhages, 0.9 mg of rt-PA was injected. The rt-PA was delivered in 3 doses over 24 hours.

Results. All patients had significant volume reductions in the treated hemorrhage. The mean percentage volume reduction after 24 hours of therapy, as determined on CT and compared with pretreatment stability scans, was 59 ± 5% (mean ± SEM) for ICH and 45.1 ± 13% for IVH (1 patient with ICH was excluded from analysis because of catheter breakage). There were no intracranial infections and no significant episodes of rebleeding according to clinical or CT assessment. One death occurred by 30 days after admission. Clinical improvements as determined by a decrease in the National Institutes of Health Stroke Scale score were demonstrated at 30 days after treatment in 7 of 9 patients. The rate of hemorrhage lysis was compared between 8 patients who completed treatment, and patient cohorts treated for IVH and ICH using identical doses of rt-PA and catheter drainage but without the ultrasound (courtesy of the MISTIE [Minimally Invasive Surgery plus T-PA for Intracerebral Hemorrhage Evacuation] and CLEAR II [Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage II] studies). Compared with the MISTIE and CLEAR data, the authors observed a faster rate of lysis during treatment for IVH and ICH in the patients treated with sonolysis plus rt-PA versus rt-PA alone.

Conclusions. Lysis and drainage of spontaneous ICH and IVH with a reduction in mass effect can be accomplished rapidly and safely through sonothrombolysis using stereotactically delivered drainage and ultrasound catheters via a bur hole. A larger clinical trial with catheters specifically designed for brain blood clot removal is warranted.

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Predictors of long-term shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

J Neurosurg 113:774–780, 2010. DOI: 10.3171/2010.2.JNS09376

The purpose of this study was to identify predictors of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH).

Methods. The authors evaluated the incidence of shunt-dependent hydrocephalus in a consecutive cohort of 580 patients with SAH who were admitted to the Neurological Intensive Care Unit of Columbia University Medical Center between July 1996 and September 2002. Patient demographics, 24-hour admission variables, initial CT scan characteristics, daily transcranial Doppler variables, and development of in-hospital complications were analyzed. Odds ratios and 95% CIs for candidate predictors were calculated using multivariate nominal logistic regression.

Results. Admission glucose of at least 126 mg/dl (adjusted OR 1.6; 95% CI 1.0–2.6), admission brain CT scan with a bicaudate index of at least 0.20 (adjusted OR 1.43; 95% CI 1.0–2.0), Fisher Grade 4 (adjusted OR 2.71; 95% CI 1.2–5.7), fourth ventricle hemorrhage (adjusted OR 1.78; 95% CI 1.1–2.7), and development of nosocomial meningitis (adjusted OR 2.2; 95% CI 1.4–3.7) were independently associated with shunt dependency.

Conclusions. These data suggest that permanent CSF diversion after aneurysmal SAH may be independently predicted by hyperglycemia at admission, findings on the admission CT scan (Fisher Grade 4, fourth ventricle intraventricular hemorrhage, and bicaudate index ≥ 0.20), and development of nosocomial meningitis. Future research is needed to assess if tight glycemic control, reduction of fourth ventricle clot burden, and prevention of nosocomial meningitis may reduce the need for permanent CSF diversion after aneurysmal SAH.

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Early Ventriculoperitoneal Shunt Placement After Severe Aneurysmal Subarachnoid Hemorrhage: Role of Intraventricular Hemorrhage and Shunt Function

Neurosurgery 66:904-909, 2010 DOI: 10.1227/01.NEU.0000368385.74625.96

This study investigated the outcome of early shunt placement in patients with poor-grade subarachnoid hemorrhage and the effect of intraventricular hemorrhage (IVH) and high proteinaceous cerebrospinal fluid (CSF) on subsequent shunt performance. METHODS:This study included 33 consecutive patients with initial Fisher grade (3/4) subarachnoid hemorrhage who had undergone conversion from external ventricular drainage (EVD) to a ventriculoperitoneal (VP) shunt and whose computed tomography scan showed IVH at the time of shunt placement. Early weaning from an EVD and conversion to a VP shunt was performed irrespective of IVH or high protein content in the CSF. RESULTS: The mean interval from EVD to VP shunt placement was 6.4 days. The mean volume of IVH was 9.44 mL, and the mean value of IVH/whole ventricle volume ratio (ie, percentage of blood suspension in the CSF) was 9.81%. The mean perioperative protein level in the CSF was 149 mg/dL. During the follow-up period, 2 patients (6.1%) required VP shunt placement, and no patients experienced complications of ventriculitis or shunt-related infection. CONCLUSION: Based on our data, earlier EVD weaning and shunt placement can effectively treat subarachnoid hemorrhage–induced hydrocephalus in patients with severe subarachnoid hemorrhage. This procedure resulted in no shunt-related infections and a 6.1% revision rate. There were fewer adverse effects of IVH and protein on shunt performance. Therefore, weaning from an EVD and conversion to a permanent VP shunt need not be delayed because of IVH or proteinaceous CSF.

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Reduced Platelet Activity Is Associated With More Intraventricular Hemorrhage

Neurosurgery: October 2009 – Volume 65 – Issue 4 – p 684-688. doi:10.1227/01.NEU.0000351769.39990.16

Intraventricular hemorrhage (IVH) is a serious complication of intracerebralhemorrhage (ICH). We hypothesized that antiplatelet medication use and platelet activity would be associated with more IVH.

METHODS: We prospectively identified patients with spontaneous ICH and measured platelet activity on admission with the VerifyNow-Aspirin assay (Accumetrics, San Diego,CA). IVH volume was quantified with the Graeb scale, divided into categories of 0 (noIVH), 1 to 2 (minimal IVH), 3 to 5 (moderate IVH), and 6 and above (severe IVH). Antiplatelet medications were prospectively recorded. We used ordinal regression to measure the effect of platelet activity after correcting for ICH location and ICH volume. Outcomes were measured at 14 days or discharge with the National Institutes of HealthStroke Scale and modified Rankin Scale (mRS) and at 28 days and 3 months with the mRS.

RESULTS: In our cohort of 73 patients, 36 had no IVH, 11 had minimal IVH, 10 hadmoderate IVH, and 16 had severe IVH. Aspirin and clopidogrel (P = 0.03 for both) were associated with less platelet activity. More IVH was related to reduced platelet activity (P =0.01) after correction for ICH volume and location without contribution from aspirin or clopidogrel use. IVH was associated with worse National Institutes of Health Stroke Scalescore (P = 0.002) and mRS score (P = 0.001) at 14 days and with mRS scores at 28 days (P= 0.02) and 3 months (P = 0.008).

CONCLUSION: Reduced platelet activity was related to more IVH as a complication of ICH. The relationship of platelet activity to IVH deserves further study.

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