Original Article

Intraventricular Administration of rt-PA in Patients with Intraventricular Hemorrhage

Authors: K N. Fountas, MD, PHD, E Z. Kapsalaki, MD, PHD, D C. Parish, MD, MPH, B Smith, MPH, H F. Smisson, MD, FACS, K W. Johnston, MD, FACS, J S. Robinson, MD, FACS

Abstract

Objective: Intraventricular hemorrhage (IVH) represents a clinicopathologic entity with a dismal prognosis. The associated mortality rate has been reported as high as 80%; the morbidity is also quite high. The use of various fibrinolytic agents (streptokinase, urokinase, and recombinant tissue-type plasminogen activator [rt-PA]) has been reported in a small number of clinical series with a very limited number of participants, yielding significant variability regarding inclusion criteria, treatment protocol, and outcome analysis.


Methods: In our prospective study, we report our experience using rt-PA in 21 patients with IVH. Patients with IVH of aneurysmal or arteriovenous malformation origin were excluded. Intraventricular administration of rt-PA was initiated within 24 hours after the ictal event (dose, 3 mg every 24 hours) through a ventricular catheter. The patients’ intracranial and cerebral perfusion pressures, cerebrospinal fluid (CSF) cell count, and head CT scans with emphasis to frontal horn dimension and inner cranium diameter at the same level ratio were collected and analyzed.


Results: Good outcome was observed in 47.5% of our patients, whereas 28.5% died and 24.0% survived with severe disability. The development of rt-PA–associated complications was as follows: new hemorrhage in 19%, infection in 14.3%, and CSF pleocytosis in 100% of patients. Permanent CSF shunt was required in 40%. The intermediate (3-month) follow up of our survivors showed no significant outcome changes compared with the immediate (1-month) follow up.


Conclusions: Intraventricular administration of rt-PA appears to be beneficial in cases of IVH even though it is occasionally associated with serious complications. Further multi-institutional studies are required for validating this treatment modality and standardizing its parameters.


Key Points


* Intraventricular hemorrhage (IVH) is a clinicopathologic entity with a dismal prognosis.


* The standard care of treatment in patients with severe IVH has been the insertion of an external ventriculostomy and draining of cerebrospinal fluid. Obstruction of the ventricular catheter is frequent in these cases because of the presence of blood clots.


* Various fibrinolytic agents have been used in limited clinical series addressing the technical difficulties associated with the functioning of an external ventriculostomy.


* Our retrospective clinical study showed better short- and intermediate-term outcome in patients with IVH treated with intraventricularly administered rt-PA.


* Intraventricular recombinant tissue-type plasminogen activator can also decrease the necessity for permanent ventriculoperitoneal shunting among the survivors.

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