Large Intraventricular Hemorrhage Research Articles

Hemorrhage Expansion Rates Before and After Minimally Invasive Surgery for Intracerebral Hemorrhage: Post Hoc Analysis of MISTIE II/III

Background Stereotactic thrombolysis for evacuation of large spontaneous intracerebral (ICH) and intraventricular hemorrhage (IVH) typically requires stabilizing the hemorrhage preoperatively. We investigated intracranial hemorrhage expansion (HE) in the pre‐ and postrandomization phase of 2 clinical trials of surgical candidates with protocolized computed tomography (CT) imaging up to 10 days after presentation. Methods Prospective assessment of sequential pre‐ and post‐randomization CT scans of 141 patients enrolled in MISTIE (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation) II/ICES (Intraoperative CT‐guided Endoscopic Surgery for ICH) and 499 patients enrolled in MISTIE III. Primary outcomes were prerandomization HE of ICH >6 mL and IVH >5 mL. Secondary outcome was postrandomization HE. Stability was defined as CT time after which no further HE was observed. We evaluated risk factors for ICH/IVH expansion using multivariable logistic regression analyses after adjustment for demographics, ICH characteristics and treatment. Results Median (interquartile range) diagnostic ICH volume was 40.4 (29.5–54.1) mL. Prerandomization HE >6 mL was detected in 216 (33.8%) subjects. Median time to hematoma stability from diagnostic CT was 7 (4.7–13.6) hours. Median diagnostic IVH volume was 0 (0–1.9) mL. IVH expansion >5 mL occurred in 40 (6.3%) with stability at 6.9 (4.7–11.2) hours. Of subjects with HE, final expansion events were not yet detected at 12 hours from diagnostic CT in 36% (ICH expansion) and 33% (IVH expansion), respectively, with 91% detected by 24 hours. Independent associations with ICH expansion included age, male sex, White race, anticoagulation, ICH volume, deep ICH location, IVH, and time from symptom onset to diagnostic CT. Postsurgical ICH expansion occurred in 24 patients (6.9%) and was associated with delay in achieving stability, number of alteplase doses, and fewer CT hypodensities on diagnostic CT but not with functional outcome. Conclusion In patients with a large ICH eligible for surgical evacuation, about two thirds of HE events stabilize within 12 hours and most within 24 hours. An earlier time window for stereotactic thrombolysis may be feasible.

Catheter Tract Hemorrhages and Intracerebral Hemorrhage Outcomes in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Trial.

Factors associated with external ventricular catheter tract hemorrhage (CTH) are well studied; whether CTH adversely influence outcomes after intracerebral hemorrhage (sICH), however, is poorly understood. We therefore sought to evaluate the association between CTH and sICH outcomes. We performed a post hoc analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial. The exposure was CTH and evaluated on serial computed tomography scans between admission and randomization (approximately 72 hours). The primary outcomes were a composite of death or major disability (modified Rankin Score >3) and mortality alone, both assessed at 6 months. Secondary outcomes were functional outcomes at 30 days, permanent cerebrospinal fluid (CSF) shunt placement, any infection, and ventriculitis. We performed logistic regression adjusted for demographics, comorbidities, sICH characteristics, and treatment assignment, for all analyses. Of the 500 patients included, the mean age was 59 (SD, ±11) years and 222 (44%) were female. CTH occurred in 112 (22.4%) patients and was more common in minority patients, those on prior antiplatelet therapy, and patients who had more than 1 external ventricular drain placed. The end of treatment intraventricular hemorrhage volume was higher among patients with CTH (11.7 vs 7.9 mL, P = .01), but there were no differences in other sICH characteristics or the total duration of external ventricular drain. In multivariable regression models, CTH was not associated with death or major disability (odds ratio, 0.7; 95% CI: 0.4-1.2) or death alone (odds ratio, 0.8; 95% CI, 0.5-1.4). There were no relationships between CTH and secondary outcomes including 30-day functional outcomes, permanent CSF shunt placement, any infection, or ventriculitis. Among patients with sICH and large intraventricular hemorrhage, CTH was not associated with poor sICH outcomes, permanent CSF shunt placement, or infections. A more detailed cognitive evaluation is needed to inform about the role of CTH in sICH prognosis.

Abstract Number ‐ 148: Emergent Carotid Artery Stenting On Acute Stroke Patients With Carotid Occlusion: Benefit Or Harm?

Introduction Almost one out of four patients with acute middle cerebral artery occlusion also have ipsilateral internal carotid artery occlusion (ICAO). The interventions for acute stroke due to extracranial ICAO with or without intracranial occlusions are still a challenge. Case series reported early revascularization reduced stroke recurrence and improved outcomes. The benefits of this intervention on hyperacute ischemic strokes (within 6 hours) were much less known. We reported here two hyperacute stroke patients who emergent CAS on ICAO. Methods Electronic medical charts were reviewed, assessing intracranial hemorrhage (ICH) in two hyperacute stroke patients resulting from emergent carotid artery stenting (CAS) on the occluded internal carotid artery (ICA). Results Case description:The first patient was a 60‐year‐old male who had acute right hemiparesis, aphasia, and left gaze deviation with NIHSS12. The last known normal was five hours ago. Head and neck CT angiography (CTA) showed left anterior M2 branch artery occlusion and left ICAO. Head CT perfusion (CTP) showed a small core infarct with a large perfusion mismatch. Emergent CAS was performed without distal embolic protection (DEP) and followed by distal mechanical thrombectomy (MT). TICI 2B recanalization was achieved. After CAS, aspirin and clopidogrel were administrated. He had a large left MCA and PCA stroke from fetal PCA. A few days later, the patient developed large intraparenchymal hemorrhage (IPH) and intraventricular hemorrhage (IVH). He expired shortly. The second was a 52‐year‐old male had acute right facial droop, aphasia, dysarthria, and decreased consciousness (NIHSS 8). CTA showed left ICAO but patent intracranial arteries. CT perfusion showed a large mismatch without core infarction. He received intravenous tPA and had emergent CAS with a DEP. Aspirin 600 mg was administrated afterward. A few hours later, he had worsened weakness. Head CT showed left IPH, IVH, and subarachnoid hemorrhages with cerebral edema, and midline shift. He was medically managed for a prolonged stay and was discharged to a rehabilitation facility. Conclusions We presented two consecutive cases of emergent revascularization of ICAO in hyperacute stroke carried a high risk of ICH with poor outcome. Our online database search found that only a few case series of emergent CAS on ICAO were reported. Overall, emergent CAS carried about 20% risk of ICH and high mortality. Other series reported angioplasty on stenotic or occluded cervical ICA lesions with MT on distal occlusions had less hemorrhagic risk because there was no need fordual antiplatelet treatment. Most emergent CAS cases were performed on tandem occlusions for faster direct access and better efficacy of distal recanalization. A futurestudy comparing hemorrhagic risk betweenemergent CAS versus angioplasty of ICAO in patients with tandem occlusions can help to establish a standard MT protocol. For isolated ICAO with patent intracranial arteries from good collaterals, CTP may not be a good guidance tool for decision‐making of emergent CAS as it can falsely show mismatch from existing collaterals due to occlusion. A randomized clinical trial of comparison of medical management versus emergent CAS on those patients is warranted.

Abstract Number ‐ 133: Intraventricular Pseudoaneurysm embolization in Moyamoya disease with NBCA

Introduction Moyamoya is a chronic occlusive cerebrovascular disease characterized by progressive steno‐occlusion of intracranial internal carotid arteries (ICAs) and their proximal branches (ACA, MCA) with development of hypertrophied collateralizing perforators. [1] Affected adults can suffer intraventricular hemorrhages (IVH) from ruptures of hypertrophic collaterals in some cases with formation of a pseudoaneurysm. [2,3] Pseudoaneurysms can be treated conservatively, by microsurgical clipping or endovascular embolization). Endovascular therapy allows easier reach and multiple treatment modalities (coiling, liquid embolization). [4‐7] Methods We present the case of a 44 year old male with Moyamoya disease who suffered a large IVH. Results The patient was brought to the ED after becoming unresponsive. A CT head showed diffuse subarachnoid and intraventricular hemorrhage. CTA revealed extensive Moyamoya disease with prominent hypertrophied ICA‐MCA perforator collaterals and irregular appearance of a right basal ganglia perforator, concerning for pseudoaneurysm. DSA showeda 4.2×3.3 mm pseudoaneurysm of a large hypertrophied perforator originating from the right ICA. A Magic 1.2 microcatheter was used over a 0.007” Hybrid microwire (both Balt, Montmorency, FR) to cannulate the perforator. A mixture of 3 cc of Lipiodol and 1 cc of n‐BCA (N‐butyl‐2‐cyanoacrylate) was injected in the aneurysm with care taken to avoid reflux into in the normal‐appearing portion of the vessel. The aneurysm was excluded from the circulation and post‐operative cone beam CT showed no evidence of large infarction or new intracranial bleeding. After several weeks of neurointensive care, the patient was discharged to rehab. Image description: A. CTA of the head demonstrating diffuse intraventricular hemorrhage (stars) and a spot sign in the territory of the right perforator collaterals concerning for aneurysm. B. DSA of the right internal carotid artery (ICA) demonstrating classic findings of moyamoya disease and a pseudoaneurysm (arrow) at the level of ahypertrophiedICA‐middle cerebral artery perforator collateral. C. Single shot X Ray of the glue cast within the aneurysm and adjacent portions of the vessel. The microcatheter tip is seen at the proximal end of the cast. D. Right ICA DSA after removal of the microcatheter demonstrates exclusion of the aneurysm from the circulation and sparing of adjacent perforator collaterals. Conclusions This abstract illustrates a rare case of pseudoaneurysm formation after rupture of a hypertrophied perforator collateral in a case of severe moyamoya disease. Treatment of these lesions should aim to exclude the aneurysm from the circulation and to preserve as much perforator as possible as these vessels supply normal parench This abstract illustrates a rare case of pseudoaneurysm formation after rupture of a hypertrophied perforator collateral in a case of severe Moyamoya disease. Treatment of these lesions should aim to exclude the aneurysm from the circulation and to preserve as much perforator as possible as these vessels supply normal parenchyma.

Intraventricular Hemorrhage Expansion in the CLEAR III Trial: A Post Hoc Exploratory Analysis.

The objective of this study was to evaluate factors associated with intraventricular hemorrhage (IVH) expansion and its association with long-term outcomes. We performed a post hoc analysis of the international, multi-center CLEAR III trial (Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage) which enrolled IVH patients between September 1, 2009, and January 31, 2015. The exposure was IVH expansion, defined as >1 mL increase in volume between baseline and stability computed tomography scans, before treatment randomization. We assessed factors associated with IVH expansion and secondarily assessed the relationship of IVH expansion with clinical outcomes: composite of death or major disability (modified Rankin Scale score, >3), and mortality alone at 6 months. The relationship of IVH expansion on ventriculoperitoneal shunt placement was additionally explored. Multivariable logistic regression was used for all analyses. Of 500 IVH patients analyzed, the mean age was 59 (±11) years old, 44% were female and 135 (27%) had IVH expansion. In multivariable regression models, factors associated with IVH expansion were baseline parenchymal intracerebral hemorrhage (ICH) volume (adjusted odds ratio [OR], 1.04 per 1 mL increase [95% CI, 1.01-1.08]), presence of parenchymal hematoma expansion: >33% (adjusted OR, 6.63 [95% CI, 3.92-11.24]), time to stability head CT (adjusted OR, 0.71 per 1 hour increase [95% CI, 0.54-0.94]), and thalamic hematoma location (adjusted OR, 1.68 [95% CI, 1.01-2.79]) while additionally adjusting for age, sex, and race. In secondary analyses, IVH expansion was associated with higher odds of poor 6-month outcomes (adjusted OR, 1.84 [95% CI, 1.12-3.02]) but not mortality (OR, 1.40 [95% CI, 0.78-2.50]) after adjusting for baseline ICH volume, thalamic ICH location, age, anticoagulant use, Glasgow Coma Scale score, any withdrawal of care order, and treatment randomization arm. However, there were no relationships of IVH expansion on subsequent ventriculoperitoneal shunt placement (adjusted OR, 1.02 [95% CI, 0.58-1.80]) after adjusting for similar covariates. In a clinical trial cohort of patients with large IVH, acute hematoma characteristics, specifically larger parenchymal volume, hematoma expansion, and thalamic ICH location were associated with IVH expansion. Given that IVH expansion resulted in poor functional outcomes, exploration of treatment approaches to optimize hemostasis and prevent IVH expansion, particularly in patients with thalamic ICH, require further study. URL: https://www. gov; Unique identifier: NCT00784134.

Association Between Intraventricular Alteplase Use and Parenchymal Hematoma Volume in Patients With Spontaneous Intracerebral Hemorrhage and Intraventricular Hemorrhage

Intraventricular thrombolysis reduces intraventricular hemorrhage (IVH) volume in patients with spontaneous intracerebral hemorrhage (ICH), but it is unclear if a similar association with parenchymal ICH volume exists. To evaluate the association between intraventricular alteplase use and ICH volume as well as the association between a change in parenchymal ICH volume and long-term functional outcomes. This cohort study was a post hoc exploratory analysis of data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 randomized clinical trial with blinded outcome assessments. Between September 1, 2009, and January 31, 2015, patients with ICH and IVH were randomized to receive either intraventricular alteplase or normal saline via an external ventricular drain. Participants with primary IVH were excluded. Data analyses were performed between January 1 and June 30, 2021. Randomization to receive intraventricular alteplase. The primary outcome was the change in parenchymal ICH volume between the hematoma stability and end-of-treatment computed tomography scans. Secondary outcomes were a modified Rankin Scale score higher than 3 and mortality, both of which were assessed at 6 months. The association between alteplase and change in parenchymal ICH volume was assessed using multiple linear regression, whereas the associations between change in parenchymal ICH volume and 6-month outcomes were assessed using multiple logistic regression. Prespecified subgroup analyses were performed for baseline IVH volume, admission ICH volume, and ICH location. A total of 454 patients (254 men [55.9%]; mean [SD] age, 59 [11] years) were included in the study. Of these patients, 230 (50.7%) were randomized to receive alteplase and 224 (49.3%) to receive normal saline. The alteplase group had a greater mean (SD) reduction in parenchymal ICH volume compared with the saline group (1.8 [0.2] mL vs 0.4 [0.1] mL; P < .001). In the primary analysis, alteplase use was associated with a change in the parenchymal ICH volume in the unadjusted analysis per 1-mL change (β, 1.37; 95% CI, 0.92-1.81; P < .001) and in multivariable linear regression analysis that was adjusted for demographic characteristics, stability ICH and IVH volumes, ICH location, and time to first dose of study drug per 1-mL change (β, 1.20; 95% CI, 0.79-1.62; P < .001). In the secondary analyses, no association was found between change in parenchymal ICH volume and poor outcome (odds ratio [OR], 0.97; 95% CI 0.87-1.10; P = .64) or mortality (OR, 0.97; 95% CI 0.99-1.08; P = .59). Similar results were observed in the subgroup analyses. This study found that intraventricular alteplase use in patients with a large IVH was associated with a small reduction in parenchymal ICH volume, but this association did not translate into improved functional outcomes or mortality. Intraventricular thrombolysis should be examined in patients with moderate to large ICH with IVH, especially in a thalamic location.

Thrombolysis for Evacuation of Intracerebral and Intraventricular Hemorrhage: A Guide to Surgical Protocols With Practical Lessons Learned From the MISTIE and CLEAR Trials.

Minimally Invasive Surgery Plus Recombinant Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) procedure was recently tested in a large phase III randomized trial showing a significant probability of functional benefit in those cases that reached the goal hematoma evacuation of ≤15 mL residual (or ≥70% removal). Benefit of thrombolysis was also identified in cases with large intraventricular hemorrhage, and achieving at least 85% volume reduction in the Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III trial. To protocolize steps in the MISTIE and CLEAR procedures in order to maximize hematoma evacuation and minimize complications. We articulate data-driven lessons and expert opinions surrounding the factors of patient selection, catheter placement, and dosing, which impacted safety and surgical performance in the MISTIE and CLEAR trials. Modifiable factors to maximize evacuation efficiency include optimizing catheter placement and pursuing aggressive dosing to achieve treatment goals, while strictly adhering to the safety steps as articulated in the respective trials. Prognostic factors that are viewed as nonmodifiable include greater initial intracerebral hemorrhage volume with irregular shape, smaller intraventricular bleeds, and the uncommon but consequential development of new bleeding during the dosing period despite strict protocol adherence. Surgeon education in this tutorial is aimed at maximizing the benefit of the MISTIE and CLEAR procedures by reviewing case selection, safety steps, treatment objectives, and technical nuances. Key lessons include stability imaging, etiology screening, and technical adherence to the protocol in order to achieve defined thresholds of evacuation.

Abstract P072: Hypertensive Emergency Presenting With Intraventricular Hemorrhage

A 34-year-old African American female with a past medical history of hypertension and medical noncompliance presented to the emergency department after being found down and unresponsive by her son. On presentation, the patient's blood pressure was found to be 298/194 with a Glasgow coma score of 4, with decerebrate posturing. The computed tomography of the head showed large acute intraventricular hemorrhage in the right lateral ventricle extending along the frontal horn into the left lateral ventricle, third and fourth ventricles, causing a 4 mm leftward shift. The patient was managed with a Nicardipine drip and underwent a bilateral ventriculostomy placement, which improved the patient's neurologic status. Following a 24 day hospital stay, the patient was alert and oriented without any significant neurologic deficits and discharged to a subacute rehab facility. Hypertension is one of the most common medical conditions affecting 50 million people in the United States and approximately 1 billion people worldwide. Approximately 1% of patients with hypertension will have a hypertensive emergency at some point in their life. The clinical manifestations of hypertensive emergencies are seen with organ dysfunction, which typically require diastolic blood pressures greater than 130mmHg, in nonpregnant adults. A severe outcome of hypertensive emergency is an intracerebral hemorrhage. In these patients, when the bleed extends into the ventricles, the mortality ranges from 50-80%. One study examined medical compliance in hypertensive patients, which showed approximately 40% of patients discontinued treatment one year after initiation of their antihypertensive medication and 4% never initiated therapy. This case illustrates the importance of compliance in hypertensive patients, as well as the dramatic ramifications that can occur with uncontrolled hypertension leading to hypertensive emergency.

Abstract TP348: Extraventricular Drain Placement is Associated With Improved Outcome After Intracerebral Hemorrhage With Intraventricular Hemorrhage

Background and Aims: Many patients with intracerebral hemorrhage (ICH) develop intraventricular hemorrhage (IVH). External ventricular drains (EVDs) are commonly placed to treat obstructive hydrocephalus, but there is little data on how much patients benefit. We explored the use of EVD in ICH patients and any association with clinical outcome. Methods: We analyzed patients with primary ICH presenting to one academic medical center between 2000-2019. Patients with ICH secondary to trauma, aneurysm, and stroke were excluded. 3 month telephone interviews were used to assess clinical outcome. Good outcome was defined as 90 day modified Rankin score (mRS) of 0-3. Results: During this period 2,486 patients presented with primary ICH. Overall, patients were 73 (+/- 13) years old; 54% were male, 46% had IVH. Factors associated with IVH presence included ICH volume (29 cm 3 vs 9 cm 3 , p &lt; 0.001), deep location (48% vs 37%, p &lt; 0.001), and lower median Glasgow Coma Scale (GCS) score (9 vs 15, p &lt; 0.001). IVH presence was associated with higher 90 day mortality (57% vs. 19%, p &lt; 0.001) and poor outcome (86% vs 47%, p &lt; 0.001). An EVD was placed in 29% of patients with IVH and 4% of those without. IVH patients with EVD were younger (67 +/- 13 vs 74 +/- 13, p &lt; 0.001), had larger IVH volumes (17 cm 3 vs 8 cm 3 , p &lt; 0.001), and had lower GCS scores (7 vs 10, p &lt; 0.001) compared to other IVH patients. In univariate analysis, EVD placement was associated with poor outcome (88% vs 85%, p &lt; 0.001) but lower 90 day mortality (53% vs 59%, p = 0.048). In multivariate analysis controlling for age, ICH and IVH volumes, and Comfort Measures Only (CMO) status, EVD placement was associated with lower 90 day mortality (OR 0.68, 95% CI 0.47 - 0.98, p = 0.041), and was associated with lower chance of poor outcome (OR 0.43, 95% CI 0.25 - 0.72, p = 0.002). However, when controlling for intubation, these associations were no longer seen with 90-day mortality (OR 1.07, 95% CI 0.72 - 1.60, p = 0.737) or with poor outcome (OR 0.68, 95% CI 0.38 - 1.23, p = 0.202). Conclusion: IVH is relatively common after ICH. In univariate analysis, EVD placement is associated with lower mortality but worse neurologic outcome. However, after controlling for potential confounding factors, EVD is associated with lower mortality and better neurologic outcome.

Third Ventricle Obstruction by Thalamic Intracerebral Hemorrhage Predicts Poor Functional Outcome Among Patients Treated with Alteplase in the CLEAR III Trial.

The Clot Lysis: Evaluating Accelerated Resolution of IVH trial examined whether irrigating the ventricular system with alteplase improved functional outcomes in patients with small intracerebral hemorrhage (ICH) and large intraventricular hemorrhage (IVH). Thalamic ICH location was common and was associated with poor outcome. One possible explanation is thalamic ICH-associated mass effect obstructing the third ventricle. We hypothesized that patients with thalamic ICH obstructing the third ventricle would have worse functional outcomes compared to patients without obstructing lesions. ICH obstruction of third ventricle was defined as third ventricle compression on 1 or more axial computed tomography slices visually impeding cerebral spinal fluid flow. If the third ventricle was casted with IVH, it was scored as such. Multivariable logistic regression analyses were used to determine whether obstruction of the third ventricle predicts poor functional outcomes defined as modified Rankin score (mRS) 4-6, higher mRS, and mortality at 180days. Models were adjusted for thalamic ICH location, ICH volume, IVH volume, age, hydrocephalus, baseline Glasgow coma scale, and percentage of low cerebral perfusion pressures during treatment. Among saline-treated patients, obstruction of the third ventricle by IVH was a significant predictor of higher mRS at 180days (OR 1.87, CI 1.01-3.47) and mortality at 180days (OR 2.73, CI 1.27-5.87) while obstruction by ICH was not. In contrast, among alteplase-treated patients, obstruction by ICH was a significant predictor of mRS 4-6 (OR 3.20, CI 1.30-7.88) and higher mRS at 180days (OR 2.33, CI 1.24-4.35), while obstruction by IVH was not. Poor outcomes were associated with mass-related obstruction of the third ventricle from thalamic ICH in alteplase-treated patients and from IVH in saline-treated patients. Once the ventricular system is cleared with alteplase, obstruction of cerebral spinal fluid flow from thalamic ICH might become important in functional recovery.

Influence of Bleeding Pattern on Ischemic Lesions After Spontaneous Hypertensive Intracerebral Hemorrhage with Intraventricular Hemorrhage.

Concomitant acute ischemic lesions are detected in up to a quarter of patients with spontaneous intracerebral hemorrhage (ICH). Influence of bleeding pattern and intraventricular hemorrhage (IVH) on risk of ischemic lesions has not been investigated. Retrospective study of all 500 patients enrolled in the CLEAR III randomized controlled trial of thrombolytic removal of obstructive IVH using external ventricular drainage. The primary outcome measure was radiologically confirmed ischemic lesions, as reported by the Safety Event Committee and confirmed by two neurologists. We assessed predictors of ischemic lesions including analysis of bleeding patterns (ICH, IVH and subarachnoid hemorrhage) on computed tomography scans (CT). Secondary outcomes were blinded assessment of mortality and modified Rankin scale (mRS) at 30 and 180days. Ischemic lesions occurred in 23 (4.6%) during first 30days after ICH. Independent risk factors associated with ischemic lesions in logistic regression models adjusted for confounders were higher IVH volume (p=0.004) and persistent subarachnoid hemorrhage on CT scan (p=0.03). Patients with initial IVH volume ≥15ml had five times the odds of concomitant ischemic lesions compared to IVH volume <15ml. Patients with ischemic lesions had significantly higher odds of death at 1 and 6months (but not poor outcome; mRS 4-6) compared to patients without concurrent ischemic lesions. Occurrence of ischemic lesions in the acute phase of IVH is not uncommon and is significantly associated with increased early and late mortality. Extra-parenchymal blood (larger IVH and visible subarachnoid hemorrhage) is a strong predictor for development of concomitant ischemic lesions after ICH.

Abstract WMP108: Defining Optimal Thresholds for Achieving Clinical Benefit in Spontaneous Intraventricular Hemorrhage

Introduction: Fibrinolytic therapy for spontaneous intraventricular hemorrhage (IVH) appears to reduce mortality with uncertain benefit on long-term functional outcomes. Threshold for volume of IVH which responds to intraventricular fibrinolytic therapy with therapeutic benefit has not been determined. Methods: CLEAR III, a randomized, multi-center, double-blinded, placebo-controlled trial was conducted to determine if pragmatically employed external ventricular drainage (EVD) plus intraventricular Alteplase improved outcome, in comparison to EVD plus saline. We analyzed of IVH volume strata from study randomization: Large IVH: volume ≥50 mL; small IVH: volume&lt;20 mL. We assessed clinical variables and outcomes by IVH volume group. Outcome measures were blinded assessment of modified Rankin score (mRS) at 30, 180 and 365 days, (with mRS&gt;3 signifying poor outcome). We performed logistic regression to evaluate outcomes by IVH volume group. Results: Among the 500 patients enrolled, 55 (11%) had IVH volumes &gt;50 mL and 222 (44.4%) had IVH volume &lt;20mL. Subjects with large volume IVH were older (mean, 62.3 vs. 58.1 years; p=0.01), had smaller ICH volume (6.1 vs. 9.9 mL; p&lt;0.001), less thalamic ICH (16.4% vs. 63.6%; p&lt;0.001), more pre-admission use of anticoagulants and antiplatelet agents and greater proportion of high intracranial pressure readings during monitoring at all thresholds (&gt;20, 30, 40 mmHg), compared to those with IVH volume &lt;50mL. Day 180 mortality and poor mRS were 49.1% and 81.8% in large volume IVH compared to 13.1% and 43.3% in small volume IVH. In logistic regression models adjusted for confounders, drainage of &gt;85% IVH volume was significantly associated with higher odds of good outcome (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3) and lower odds of mortality (OR, 0.3; 95% CI, 0.1-0.8) compared to &lt;85% drainage, in patients with baseline volumes &lt;50mL. Removal of &gt;85% IVH volume (n=3/55) was not associated with improved outcomes in patients with large IVH. Conclusions: IVH volume &gt;50mL may represent a cohort without identified benefit from fibrinolytic treatment. Defining an upper limit for IVH volume would benefit from a larger sample and other methods of achieving IVH reduction.

Not “Doing the Same Thing Over and Over Again”

Intracerebral hemorrhage (ICH) with intraventricular extension is a devastating disease occurring in 40% of patients with spontaneous ICH. Although the CLEAR III trial (NCT00784134) demonstrated mortality reduction with intraventricular alteplase (versus saline), lessons learned warrant a therapeutic trial focusing on disease severity and treatment endpoints that support a high likelihood of improvement. We must answer questions of maximizing therapy intensity in large intraventricular hemorrhage (IVH) to promote good neurologic outcomes if we are committed to treating ICH and the full spectrum of stroke severity.

Pituitary apoplexy presenting as an intraventricular hemorrhage: An infrequent neurovascular emergency

Abstract Pituitary macroadenomas may present with a pituitary apoplexy, commonly with associated hemorrhage, but rarely large enough to show an intraventricular bleeding. This is a case report of a 66-year-old woman with a 3-month history of headache, hyporexia, asthenia and altered consciousness. First evaluations showed a large intraventricular hemorrhage on CT scan that was initially misdiagnosed for an aneurysmal rupture etiology but later confirmed to be a pituitary apoplexy from a large pituitary adenoma. Intraventricular hemorrhage due to a pituitary apoplexy could be mistaken for an aneurysmal origin thus warranting for a careful evaluation of the sellar region.

Use and Timing of Tracheostomy After Severe Stroke.

A patient with severe ischemic or hemorrhagic stroke needs to have a tracheostomy performed if he remains unable to breathe and protect his airway sufficiently. This can be caused by very different types of stroke, such as severe acute ischemic stroke (eg, large hemispheric stroke, space-occupying cerebellar stroke, basilar thrombosis, and brain stem infarction), large or brain stem intracerebral hemorrhage and intraventricular hemorrhage, severe cerebral venous and sinus thrombosis, and aneurysmal subarachnoid hemorrhage. The particular type of cerebrovascular pathology is probably less relevant than how extensive the brain damage and its sequelae (brain edema, secondary ischemia) are and what parts of the brain they affect. In particular, compromise of brain regions regulating the level of consciousness (reticular formation in the brain stem, thalami, limbic system), breathing (respiratory centers in the cortex, pons, and medulla), and swallowing (medulla and brain stem connections) may lead to the need of a tracheostomy. There are 2 main scenarios in which tracheostomy after stroke is usually considered. The first is in a patient requiring stroke unit care with an overall moderate stroke that affects swallowing centers of the brain (such as infarcts of the brain stem or the medulla oblongata) causing dysphagia. In some of those cases, after several noninvasive supportive measures have been sufficiently applied but failed, tracheostomy may be considered to prevent aspiration and bridge swallowing therapy. This approach to that scenario, however, is very controversial. The second scenario is in a patient with a stroke so severe to demand admission to an intensive care unit (ICU) and mechanical ventilation. There, tracheostomy will be chosen if extubation fails or is deemed not feasible, that is, as part of weaning from the ventilator. The need of tracheostomy, the timing of tracheostomy, and its potential benefits versus risks to the patient with severe stroke remain …

Use of tissue plasminogen activator in the treatment of shunt blockage secondary to intraventricular haemorrhage

A 51-year-old woman with a history of idiopathic aqueduct stenosis, treated initially with insertion of a ventriculo peritoneal shunt, presented to our institution with shunt dysfunction. She had previously undergone multiple shunt revisions for shunt infection, shunt blockage and low-pressure symptoms, most recently with conversion to a ventriculo atrial (VA) shunt. Her VA shunt was again revised, with replacement of the ventricular catheter, however surgery was complicated by a large intraventricular haemorrhage (IVH) requiring placement of an external ventricular drain (EVD). Prior to eventual removal of her EVD it was determined that the VA shunt had blocked as a result of the IVH. Subsequently alteplase, a recombinant tissue plasminogen activator (tPA), was administered into the shunt reservoir, resulting in successful return of shunt function, therefore avoiding the need for further shunt revision. This is the first description of the use of tPA to unblock a shunt obstructed by blood.

Abstract WMP87: Inflammatory Response in Cerebrospinal Fluid is Triggered by Large Volume Intraventricular Hemorrhage

Introduction: Cerebrospinal fluid (CSF) pleocytosis has been consistently observed with intraventricular hemorrhage (IVH) in small case series. Its extent, time course, and relation to IVH volume and infection have never been studied in a large cohort with systematic data collection. Hypothesis: Inflammatory response in CSF follows a predictable pattern after IVH, and is more enhanced in cases with higher IVH volume and infection Method: We analyzed prospectively collected samples from 500 patients enrolled in the Clot Lysis Evaluation of Accelerated Resolution (CLEAR) phase III trial. Patients with obstructive IVH requiring external ventricular drainage (EVD) were randomized to receive thrombolytic or placebo injections via EVD. We analyzed 12,291 data points including daily peripheral WBC and RBC counts, CSF RBC, WBC and neutrophil count, protein and glucose. Corrected WBCs (coWBC) reflecting true inflammatory response in the CSF was calculated by controlling for RBC/WBC ratio in a contemporaneous blood sample of the patient. Consecutive values were adjusted to the date of ictus (day 0) and analyzed on days 1-9. Median daily values were chronologically plotted to define the temporal pattern for each parameter. Similar analyses were repeated after stratification based on IVH volume, time to EVD insertion, and presence of culture positive ventriculitis (14 cases, 3%) Result: CSF protein gradually declined with later clearance of RBCs after IVH. There was a surge in coWBC at days 3-5. All parameters of inflammatory response, and most notably the coWBC peak, were greater with larger volume of IVH. Subgroup analyses defined a threshold for significant inflammatory response with initial IVH volume 27mls (P=0.006). Bacterial ventriculitis resulted in significantly higher coWBCs (P&lt;0.001) and neutrophils (P=0.01), but only in cases with low volume IVH (&lt;27ml) Conclusion: Inflammation is an integral response to IVH and is more pronounced with large IVH volume. Bacterial ventriculitis is associated with CSF leukocytosis exceeding the aseptic inflammatory response, notably in lower volume bleeds. These results form a basis for future correlation with treatment rendered, rate of IVH clearance and clinical outcome, with upcoming unblinding of the trial.

Progress in Neonatal Neurology with a Focus on Neuroimaging in the Preterm Infant.

There have been tremendous changes in the methods used to evaluate brain injury in the preterm infant in the past 30 years. In particular, major improvements have been made in how we use neuroimaging techniques and now magnetic resonance imaging (MRI) is used more often and considered complimentary to routine and sequential cranial ultrasound. The focus has shifted from severe lesions such as large intraventricular and parenchymal hemorrhages and cystic periventricular leukomalacia to assessing and understanding the etiology of more subtle noncystic white matter injury, punctate hemorrhage, and cerebellar lesions. The more severe lesions that dominated the early period of preterm neonatal brain imaging occur less frequently but are still associated with major disabilities, such as, cerebral palsy, while subtle white matter injury and cerebellar lesions are more often associated with cognitive and behavioral problems, which have become the most prevalent issues among the survivors of extremely preterm birth.

The Risk Factors for Hydrocephalus and Subdural Hygroma after Decompressive Craniectomy in Head Injured Patients.

ObjectiveThe present study aims to investigate 1) the risk factors for hydrocephalus and subdural hygroma (SDG) occurring after decompressive craniectomy (DC), and 2) the association between the type of SDG and hydrocephalus.MethodsWe retrospectively reviewed the clinical and radiological features of 92 patients who underwent DC procedures after severe head injuries. The risk factors for developing post-traumatic hydrocephalus (PTH) and SDG were analyzed. Types of SDGs were classified according to location and their relationship with hydrocephalus was investigated.ResultsUltimately, 26.09% (24/92) of these patients developed PTH. In the univariate analyses, hydrocephalus was statically associated with large bone flap diameter, large craniectomy area, bilateral craniectomy, intraventricular hemorrhage, contralateral or interhemisheric SDGs, and delayed cranioplasty. However, in the multivariate analysis, only large craniectomy area (adjusted OR=4.66; p=0.0239) and contralateral SDG (adjusted OR=6.62; p=0.0105) were significant independent risk factors for developing hydrocephalus after DC. The incidence of overall SDGs after DC was 55.43% (51/92). Subgroup analysis results were separated by SDG types. Statistically significant associations between hydrocephalus were found in multivariate analysis in the contralateral (adjusted OR=5.58; p=0.0074) and interhemispheric (adjusted OR=17.63; p=0.0113) types.ConclusionFor patients who are subjected to DC following severe head trauma, hydrocephalus is associated with a large craniectomy area and contralateral SDG. For SDGs after DC that occur on the interhemispherical or controlateral side of the craniectomy, careful follow-up monitoring for the potential progression into hydrocephalus is needed.

E-017 Cerebrovascular Decision Making: Professional and Personal Preferences

IntroductionIt is known that physicians sometimes recommend treatment that, in a similar clinical scenario, they might not choose for themselves. We sought to understand this dynamic across cerebrovascular practice and...