Treatment Of Severe Intraventricular Hemorrhage Research Articles

Clinical study on the treatment of severe intraventricular hemorrhage by using neuroendoscopy combinedwith ventricular irrigation

Objective To explore the efficacy of neuroendoscopy combined with ventricular irrigation in the treatment of severe intraventricular hemorrhage. Methods A retrospective study was conducted on 145 cases of severe intraventricular hemorrhage admitted to Department of Neurosurgery at Harrison International Peace Hospital Affiliated to Hebei Medical University from January 2015 to November 2017. Among them, 65 cases were treated by neuroendoscopy combined with ventricular irrigation (neuroendoscope group) and 80 were treated with external ventricular drainage (drilling drainage group). The hospital stay length, recovery time of cerebrospinal fluid, intracranial infection rate, hematoma clearance and rebleeding rate at 6h post operation were compared between the 2 groups. After 6 months of follow-up, the occurrence of hydrocephalus was assessed according to CT examination and the patient's outcome was assessed according to the activity of daily living (ADL) score. The Bsrsel index≥90% indicated that the patient had a good outcome. Results Compared with the drilling drainage group, the recovery time of cerebrospinal fluid after neuroendoscopy was shortened (3.9±0.9 min vs. 4.6±1.1 min, P=0.034), the clearance rate of hematoma was significantly higher [23.1%(15/65) vs. 2.5%(2/80), P 0.05). After 6 months, the rate of good outcome in the neuroendoscopy group was better than in the drilling drainage group [50.8%(33/65) vs. 28.8%(23/80), P=0.001]. The occurrence rate of hydrocephalus [4.6%(3/65) vs. 16.3%(13/80)] and mortality rate [4.6%(3/65) vs. 15.0%(12/80)] were lower than those in the drilling drainage group(both P<0.05). Conclusion Neuroendoscopy combined with ventricular irrigation could effectively improve clinical efficacy, reduce complications and improve the outcome of severe ventricular hemorrhage, which might be worthy of clinical promotion. Key words: Natural cavity endoscopic; Neurosurgery; Treatment results; Severe intraventricular hemorrhage; Ventricular irrigation

IMPROVED NEUROLOGICAL ASSESSMENT OF SEVERE INTRAVENTRICULARHEMORRHAGE IN NEWBORNS WITH VERY LOW AND EXTREMELY BIRTH WEIGHT

Neurological outcomes in severe intraventricular hemorrhage in infants with very prematurity de- termined by correctable and uncorrectable factors of bleeding. The aim of the study was to develop an optimal clinical diagnostic algorithm in selection of treatment of severe intraventricular hemorrhage in infants born with critical immaturity. During the period 2005-2010. He received treatment at the hospi- tal in 1150 infants with very low birth weight (VLBW), and extremely low birth weight (ELBW). We used clinical methods of evaluation: neurological examination, pediatric Glasgow Coma Scale / Saint Petersburg (Iova A.S. et al., 1999). Diagnostic methods: ulrasonografiya (US), computed tomography (CT), magnetic resonance imaging (MRI).Ways of improving diagnostic tactics depending on the risk factors and the dynamic clinical and ultrasonographic evaluation. Adoption subgaleal drainage when post-hemorrhagic ventriculodilatation improves early neurological outcomes in children.

Occurrence and impact of intracranial pressure elevation during treatment of severe intraventricular hemorrhage*

Elevated intracranial pressure is one of the proposed mechanisms leading to poor outcomes in patients with intraventricular hemorrhage. We sought to characterize the occurrence and significance of intracranial hypertension in severe intraventricular hemorrhage requiring extraventricular drainage. Prospective analysis from two randomized, multicenter, clinical trials. Intensive care units of 23 academic hospitals. One hundred patients with obstructive intraventricular hemorrhage and intracerebral hemorrhage volume <30 mL requiring emergency extraventricular drainage from two randomized multicenter studies comparing intraventricular recombinant tissue plasminogen activator (n=78) to placebo (n=22). Intracranial pressure was recorded every 4 hrs in all patients and before and after a 1-hr extraventricular drainage closure period after injection. Intracranial pressure readings were analyzed at predefined thresholds and compared between treatment groups, before and after injection of study agent, and before and after opening of third and fourth ventricles on computed tomography. Impact on 30-day outcomes was assessed. Initial intracranial pressure ranged from -2 to 60 mm Hg (median; interquartile range, 11;10). Of 2576 intracranial pressure readings, 91.5% (2359) were ≤20 mm Hg, 1.6% were >30, 0.5% were >40, and 0.2% were >50 mm Hg. In a multivariate analysis, threshold events>20 mm Hg and >30 mm Hg were more frequent in placebo vs. recombinant tissue plasminogen activator-treated groups (p=.03 and p=.08, respectively). Intracranial pressure elevation>20 mm Hg occurred during a required 1-hr extraventricular drainage closure interval in 207 of 868 (23.8%) injections of study agent, although early reopening of the extraventricular drainage only occurred in 7.9%. After radiographic opening of the lower ventricular system, intracranial pressure events>20 mm Hg remained significantly associated with initial intraventricular hemorrhage volume (p=.002) and extraventricular drainage placement ipsilateral to the largest intraventricular hemorrhage volume (p=.001), but not with thrombolytic treatment (p=.05) or intracerebral hemorrhage volume (p=.14). Ventriculoperitoneal shunts were required in 13.6% of placebo and 6.4% of recombinant tissue plasminogen activator-treated patients (p=.37). Percentage of intracranial pressure readings per patient>30 mm Hg and initial intracerebral hemorrhage and intraventricular hemorrhage volumes were independent predictors of 30-day mortality after adjustment for other outcome predictors (p=.003, p=.03, and p<.001, respectively). Independent predictors of poor modified Rankin Scale score at 30 days were percent of intracranial pressure events>30 mm Hg per patient (p=.01; but not >20 mm Hg), both intracerebral hemorrhage and intraventricular hemorrhage volume, and pulse pressure. Intracranial pressure is not frequently elevated during monitoring and drainage with an extraventricular drainage in patients with severe intraventricular hemorrhage, although intracranial pressure >30 mm Hg predicts higher short-term mortality. Thrombolytic therapy may reduce the frequency of high intracranial pressure events. Intracranial pressure elevation appears to be significantly correlated with extraventricular drainage placement in the ventricle with greatest clot volume.

Factors Affecting Clot Lysis Rates in Patients With Spontaneous Intraventricular Hemorrhage

In the treatment of severe intraventricular hemorrhage (IVH), thrombolytic use and clot size are known to influence clot lysis rates. We evaluated the effect of other variables on IVH clot lysis rates among patients treated with recombinant tissue-type plasminogen activator or placebo. One hundred patients with IVH and intracerebral hemorrhage volume <30 mL requiring emergency external ventricular drainage from 2 multicenter trials were treated with intraventricular administration of recombinant tissue-type plasminogen activator (n=78; 53 males, 25 females) or placebo (n=22; 7 males, 15 females). IVH volume was quantified daily by head CT. A segmented linear regression using an optimized spline knot for each patient was fit. Random effects linear regression was used to estimate the effect of prespecified patient characteristics on clot lysis rates over the first 6 days. Stability IVH volumes were larger in males (N=60; 54 ± 5 mL) than females (N=40; 36 ± 5 mL; P=0.01). Intraventricular thrombolytic treatment was associated with an increase in clot lysis rate of 14.6% of stability IVH volume/day before the spline knot compared with the placebo group (P<0.001). After adjustment for thrombolytic, higher baseline serum plasminogen and lower baseline platelet count were independently associated with an increase in clot lysis of 1.28%/day per 10-g/dL increase (P<0.001) and 0.70% /day per 10×10(3)/uL decrease (P<0.001) before the knot, respectively. Although thrombolysis remains the major determinant of IVH clot lysis rate, higher baseline serum plasminogen and lower platelet count also predict faster clot lysis. Further studies are needed to confirm whether plasminogen availability and thrombus structure impact IVH clot removal. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00650858.

Frequency of Sustained Intracranial Pressure Elevation during Treatment of Severe Intraventricular Hemorrhage

Background: Elevated intracranial pressure (ICP) is an important marker of neurological deterioration. The occurrence and significance of elevated ICP and low cerebral perfusion pressure (CPP) in aggressively treated spontaneous intraventricular hemorrhage (IVH) are not defined. Methods: We performed a secondary longitudinal exploratory data analysis of a randomized multicenter trial of urokinase (UK) versus placebo (Pcb) as a treatment for IVH. Eleven IVH patients who required an external ventricular drain (EVD) were randomized to receive either intraventricular UK or Pcb every 12 h until clinical response permitted EVD removal. ICP and CPP were recorded every 4 or 6 h, as well as before and 1 h after EVD closure for administration of study agent. ICP, CPP and the proportion of ICP readings above 20, 30, 40 and 50 mm Hg were analyzed. Results: Six UK and 5 Pcb patients aged 39–74 years (mean ± standard deviation; 53 ± 11 years) were enrolled. Initial ICP ranged from 0 to 38 mm Hg (10.9 ± 11.0), initial CPP from 65 to 133 mm Hg (100.5 ± 17.7). We recorded 472 ICP readings over the entire monitoring period. Of these 65 (14%) were >20 mm Hg, 23 (5%) >30 mm Hg, 9 (2%) >40 mm Hg and 3 (<1%) >50 mm Hg. Only 2 of 141 intraventricular injections of study agent with EVD closure were not tolerated and required reopening of the EVD. Conclusions: In the intensive care unit, initial ICP measured with an EVD was uncommonly elevated (1/11 patients) in this group of severe IVH patients despite acute obstructive hydrocephalus. Frequent monitoring reveals ICP elevation >20 mm Hg in 14% of observations during use of EVD. ICP elevation, though it can occur, is not routinely associated with EVD closure for thrombolytic treatment with UK.

Treatment of severe intraventricular hemorrhage by intraventricular infusion of urokinase

During the last three years, seven patients with severe intraventricular hemorrhage admitted to our clinic were treated with direct intraventricular infusion of urokinase. In each case, hemorrhage extended into the entire ventricular cavity and cast formation as well as an expansion of third and fourth ventricles were found. On the average, both the third and fourth ventricles became clear on the third day and the lateral ventricle on the ninth day after hemorrhage. Five of the seven patients showed good recovery or only moderate disability, and two died. Infection, convulsion, rebleeding, and peripheral or secondary hemorrhage due to the side effects of urokinase was not encountered during therapy. We conclude that this procedure can be applied effectively and safely in severe intraventricular hemorrhage.

Treatment of severe intraventricular hemorrhage by intraventricular infusion of urokinase

Six patients with severe intraventricular hemorrhage were treated with direct intraventricular infusion of urokinase. In each case, hemorrhage extended into all ventricular chambers, and a cast formation and expansion of the third and fourth ventricles were found. Immediately after the therapy was started (within 7 days from onset of symptoms), reduction of intraventricular hematoma volume was observed on computerized tomography. On average, both the third and fourth ventricles became clear on the third day after hemorrhage; there was one exception, a case of ruptured aneurysm. Five of the six patients showed excellent or good outcome, although two developed delayed hydrocephalus. No infection or rebleeding was observed. The outcome in a retrospectively studied group of five patients not treated with urokinase is also reported. The authors conclude that this relatively easy method of treatment will greatly improve the prognosis of severe intraventricular hemorrhage.