Cohort study of intraventricular thrombolysis with recombinant tissue plasminogen activator for aneurysmal intraventricular hemorrhage.
OBJECTIVE
Thrombolytic agents have been administered through external ventricular drains to treat intraventricular hemorrhage, the goals being to accelerate clot clearance, prevent catheter obstruction, and help control intracranial pressure. We compared these variables in a group of aneurysm patients treated by one surgeon who routinely used intraventricular recombinant tissue plasminogen activator (rt-PA) for obstructive hematocephalus with those in a group of similar patients treated by other surgeons who did not.


METHODS
Patients included in this analysis were those with repaired cerebral aneurysms causing hemorrhage into at least three ventricles with ventriculomegaly requiring external ventricular drainage. The ventricular system was considered "opened" when all ventricles were patent and reduced in size on computed tomographic scans. Those treated with rt-PA received 4 mg/d through a ventricular drain until ventricular opening.


RESULTS
The mean number of days to ventricular opening was 3.9 (standard deviation [SD], 1.0) for the 21 patients treated with rt-PA and 7.1 (SD, 3.7) for the 9 who were not (P = 0.001), and the mean intracranial pressure (mm Hg) 24 hours after treatment with rt-PA was 10.4 (SD, 6.1) compared with 14.1 (SD, 5.9) during the same interval for the group that did not receive rt-PA (P = 0.13). Ventricular catheter replacement was required in 1 rt-PA patient (for a misplaced catheter, before rt-PA treatment) and 3 patients who did not receive rt-PA (all for catheter obstructions with blood clot) (P = 0.07), and ventriculoperitoneal shunts were placed in 4 rt-PA patients and 3 patients who did not receive rt-PA (P = 0.4).


CONCLUSIONS
Intraventricular thrombolysis with rt-PA seems to assist in the acute management of patients with large aneurysmal intraventricular hemorrhages, speeding clearance of aneurysmal intraventricular hemorrhage, normalizing intracranial pressure, and reducing ventricular catheter obstruction. A randomized trial is needed to confirm these findings, establish treatment safety, and determine whether treatment affects outcome.
Findlay
J Max
JM
Division of Neurosurgery, Department of Surgery, Walter Mackenzie Health Science Centre, Edmonton, Alberta, Canada. mfindlay@cha.ab.ca
Jacka
Michael J
MJ
D000328:Adult; D000368:Aged; D017542:Aneurysm, Ruptured / Q000150:complications; D002552:Cerebral Ventricles / Q000187:drug effects; D015331:Cohort Studies; D004185:Disability Evaluation; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D005500:Follow-Up Studies; D006801:Humans; D007276:Injections, Intraventricular; D002532:Intracranial Aneurysm / Q000150:complications; D007427:Intracranial Pressure / Q000187:drug effects; D020767:Intracranial Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000009:adverse effects; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D014057:Tomography, X-Ray Computed; D014696:Ventriculostomy
D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator