CSF and other interventions

Abstract

The present talk reviews newer studies with a focus on CSF management in intraventricular hemorrhage and some selected non-surgical interventions in ICH. Intraventricular hemorrhage is a well-established negative prognostic predictor in ICH and different treatment approaches for this condition have been investigated in the recent years. Intraventricular fibrinolysis has been tested in the CLEAR III trial and showed reduced mortality, however no significant difference in clinical outcome as compared to placebo. A subgroup of patients in CLEAR III, namely those with higher IVH volume who were treated until better IVH removal was achieved (>80% of initial volume), benefited from intraventricular tpA. Although IVH removal can be achieved faster with intraventricular fibrinolysis, blood breakdown products still lead to permanent aresorptive hydrocephalus in approximately 15–30% of patients. A recent study (LUCAS-IVH) has investigated a combined approach of intraventricular fibrinolysis and lumbar drainage of CSF after severe IVH, as compared to intraventricular fibrinolysis alone. Lumbar drainage was applied after re-opening of the third and fourth ventricle and led to significantly less shunt surgery. Faster removal of blood degradation products may play a role as a possible mechanism of action in this treatment approach. The only acute treatment in intracerebral hemorrhage that has recently changed based on new results from clinical trials is blood pressure management. After the INTERACT 2 trial showed benefit from intensive BP control, treatment guidelines were adapted. The later published ATACH trial showed no benefit from intensive BP control (110–139 mmHg) as compared to standard treatment (140–179 mmHg systolic BP). Recent subanalyses show that reduction of ICH growth achieved by intensive BP control is somewhat offset by cardio-renal complications. The TICH 2 trial compared treatment with tranexamic acid against placebo in patients with acute ICH within 8h from symptom onset and could not show a significant benefit in clinical outcome. Although there was significantly less ICH growth in the verum group, the absolute difference was small (appr. 1.2 ml less on average). Perihemorrhagic edema is increasingly being recognized as a treatment target after ICH. Non-surgical treatment strategies used in the clinical routine like mannitol and hypertonic saline are presently not based on robust evidence from clinical trials. Deferoxamine did not show promising results in the recently published i-DEF phase II trial. Data on antiinflammatory treatment approaches are still lacking. Hypothermia and machine-based targeted temperature management have only been investigated in small trials on severely affected patients.