Safety and Efficacy of Transcatheter Administration of Tissue Plasminogen Activating Factor as Adjuvant Therapy for Intraventricular Hemorrhage.

Mark Krel,Dan E Miulli,Stacey Podkovik,Margaret Rose Wacker,Yancey Beamer,James Brazdzionis

doi:10.7759/cureus.5785

Abstract

ObjectiveStroke 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.MethodsRetrospective 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.ResultsPresenting 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.ConclusionThese 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.

Highlights

Stroke is the fifth leading cause of death in the United States and the leading cause of long-term debility
Patients were eligible for inclusion in this study if they experienced an intraventricular hemorrhage resulting in hydrocephalus, which was treated with an external ventricular drain and subsequent transcatheter intraventricular recombinant tissue plasminogen activating factor (rt-PA)
Limited by small sample size, the calculated probability of a type I error in all conditions that proved to be significant was quite small. While this is insufficient for Level Ia recommendation to clinical practice, it argues strongly in favor of larger prospective trials of rt-PA protocol inception at External Ventricular Drain (EVD) day two for patients presenting with acute intraventricular hemorrhage

Summary

Introduction

Stroke is the fifth leading cause of death in the United States and the leading cause of long-term debility. Hemorrhagic stroke has been shown to have an overall higher risk of mortality in the acute phase with the risk of mortality and permanent neurologic deficit being higher still in patients who presented with acute intraventricular hemorrhage (IVH). Among the largest and best known of these trials is the Clot Lysis Evacuation of Accelerated Resolution (CLEAR) series of trials These trials suggest the feasibility and efficacy of transcatheter administration of recombinant tissue plasminogen activator (rt-PA) for acute intraventricular hemorrhage. They have demonstrated a concomitant reduction in mortality [8]

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Discussion

Conclusion