Intraventricular fibrinolysis and lumbar drainage for ventricular hemorrhage.
OBJECTIVE
Both intraventricular fibrinolysis (IVF) and lumbar drainage (LD) may reduce the need for exchange of external ventricular drainage (EVD) and shunt surgery in patients with intracerebral hemorrhage and severe intraventricular hemorrhage. We investigated the feasibility and safety of IVF followed by early LD for the treatment of posthemorrhagic hydrocephalus.


METHODS
This prospective study included patients with spontaneous ganglionic intracerebral hemorrhage and severe intraventricular hemorrhage with acute obstructive posthemorrhagic hydrocephalus who received an EVD (n=32). The treatment algorithm started with IVF (4 mg recombinant tissue plasminogen activator every 12 hours) until clearance of the third and fourth ventricles from blood. Thereupon, EVD was clamped and if clamping was unsuccessful, communicating posthemorrhagic hydrocephalus was assumed and LD placed. EVD was removed if there was neither an increase of intracranial pressure nor ventricle enlargement on CT. A ventriculoperitoneal shunt was indicated if "LD weaning" was unsuccessful for >10 days. Outcome was assessed at 90 and 180 days using the modified Rankin Scale.


RESULTS
IVF resulted in fast clearance of the third and fourth ventricles (73+/-50 hours). However, early EVD removal was only possible in 4 patients. The remaining 28 patients developed communicating posthemorrhagic hydrocephalus. In all of these patients, early LD was capable to replace EVD. EVD exchange was not necessary and EVD duration was 105+/-59 hours. Only one patient required a ventriculoperitoneal shunt. At 180 days, 20 (62.5%) patients had a good (modified Rankin Scale 0 to 3) outcome and 5 (15.6%) patients had died. One patient had asymptomatic ventricular rebleeding.


CONCLUSIONS
In patients with secondary intraventricular hemorrhage and posthemorrhagic hydrocephalus, the combined treatment approach of IVF and early LD is safe and feasible, avoids EVD exchange, and may markedly reduce the need for shunt surgery.
Staykov
Dimitre
D
Department of Neurology, University of Erlangen, Erlangen, Germany. dimitre.staykov@uk-erlangen.de
Huttner
Hagen B
HB
Struffert
Tobias
T
Ganslandt
Oliver
O
Doerfler
Arnd
A
Schwab
Stefan
S
Bardutzky
Juergen
J
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D002543:Cerebral Hemorrhage / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery*; D002985:Clinical Protocols; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D020546:Fourth Ventricle / Q000473:pathology / Q000503:physiopathology; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control / Q000601:surgery; D019586:Intracranial Hypertension / Q000503:physiopathology / Q000517:prevention & control; D020547:Lateral Ventricles / Q000187:drug effects* / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013129:Spinal Puncture / Q000379:methods*; D020542:Third Ventricle / Q000473:pathology / Q000503:physiopathology; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D016896:Treatment Outcome; D014696:Ventriculostomy / Q000379:methods
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator