Tag: Thrombolysis

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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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Intraventricular Tissue Plasminogen Activator for the Prevention of Vasospasm and Hydrocephalus After Aneurysmal Subarachnoid Hemorrhage

Neurosurgery 67:110-117, 2010 DOI: 10.1227/01.NEU.0000370920.44359.91

The sequelae of aneurysmal subarachnoid hemorrhage (SAH) include vasospasm and hydrocephalus.

OBJECTIVE: To assess whether intraventricular tissue plasminogen activator (tPA) results in less vasospasm, fewer angioplasties, or fewer cerebrospinal fluid shunting procedures.

METHODS: 41 patients (tPA group, Hunt and Hess 3, 4, 5) from 2007 to 2008 received intraventricular tPA and lumbar drainage for a minimum of 5 days (range 5-7 days) and were compared to a matched group of 35 patients from 2006 to 2007 (Control, HH 3, 4, 5). Statistical comparison was done by t test analysis or Fisher exact tests and data are expressed as average ± standard error of the mean.

RESULTS: There were no significant differences in demographic data, although the tPA group had a trend toward more surgical patients. The tPA group of patients had a significantly higher modified Fisher grade than controls (P < .001) and had a significantly better Hunt and Hess grade than controls (P < .03). The angioplasty rate was significantly lower among the tPA patients (15.0% ± 5.6) than controls (40.0% ± 8.5, P = .019). The number of days spent in severe vasospasm normalized over the 14-day monitoring period by transcranial Doppler was significantly lower in the tPA group (0.09 ± 0.02) than controls (0.17 ± 0.03). The shunt rate was significantly lower among tPA patients (17.5% ± 6.0) than controls (42.8% ± 8.6). There were 2 clinically silent tract hemorrhages in the tPA group (4.8%).

CONCLUSION: Intraventricular tPA is a safe and effective treatment for reducing both angioplasty and shunting rates in patients with SAH H&H Grades 3 to 5. A randomized trial is indicated.

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