Safety of Intraventricular Hemorrhage (IVH) Thrombolysis Based on CT Localization of External Ventricular Drain (EVD) Fenestrations and Analysis of EVD Tract Hemorrhage
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The purpose of the study is to review the CT findings associated with ventriculostomy placement in regards to the safety of an EVD plus recombinant tissue plasminogen activator (rt-PA) for IVH.
A retrospective review was conducted for patients receiving intraventricular rt-PA for IVH from January 2004 to September 2009. Safety was assessed by the presence of EVD tract hemorrhage by CT at baseline after EVD placement, worsening hemorrhage after rt-PA, and CSF infection. IVH volumetrics were assessed by the Le Roux score and outcomes by Glasgow Outcome Scale and modified Rankin Scale.
Twenty-seven patients received rt-PA for IVH. Median dose was 2 mg (range 0.3–8) and a median of two doses (range 1–17) were given. Worsening EVD catheter tract hemorrhage after rt-PA was 46.7 %, with a significantly higher incidence of worsening tract hemorrhage seen with incorrectly placed EVDs (p = 0.04). IVH hematoma burden decreased by a median Le Roux score of 10 (range 3–16) prior to rt-PA to 4 (range 0–16) after rt-PA. There were no central nervous system bacterial infections.
Intraventricular rt-PA appears to be relatively safe especially when all EVD fenestrations are within the ventricle and reduces IVH burden similar to other studies. We describe a CT-based EVD tract hemorrhage grading scale to evaluate EVD tract hemorrhage before and after thrombolysis, and a bone-window technique to evaluate EVD fenestrations prior to IVH thrombolysis. Further research is needed evaluating these imaging techniques in regard to intraventricular thrombolytic safety and EVD tract hemorrhage.
KeywordsIntracerebral hemorrhage Intraventricular hemorrhage Cerebrovascular disease Stroke Critical care
The authors would like to acknowledge the contributions of the following colleagues: Paula Fuqua, PharmD, CCRC; Jamila Russeau PharmD, BCPS; Leah Ward PharmD; and Amy Swan M.S., PharmD, for guidance and assistance in study protocol development and manuscript review. Michael Heckman, MS for general advice on using appropriate statistics for this study. Tara Brigham, MLIS and Victoria Jackson, MLIS for reviewing and formatting the final manuscript.
Dr. Jackson reports no disclosures. Dr. Patel reports no disclosures. Dr. Darracott reports no disclosures. Dr. Hanel serves as a scientific advisor for NeuroVasx, Inc. although it is unrelated to this study. Dr. Freeman receives research support for his time involved as a site investigator in the CLEAR IVH III trial, NIH grant # U01 NS062851, which is a NINDS-Genentech funded study with Dr. Daniel F. Hanley as the principle investigator. Dr. Hanley receives research support for his time involved as principle investigator in the following clinical trials: CLEAR IVH III (NIH grant # U01 NS062851) and MISTIE ICH (NIH grant # U01 PAR 10198), which are NIH-NINDS funded studies; and as Jeffrey & Harriet Legum Professor at Johns Hopkins University.
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