title: Safety of intraventricular hemorrhage (IVH) thrombolysis based on CT localization of external ventricular drain (EVD) fenestrations and analysis of EVD tract hemorrhage.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Pharmacy, Mayo Clinic, Jacksonville, FL, USA.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Jackson
authors.forename: Alden V
authors.initials: AV
authors.lastname: Patel
authors.forename: Robert M
authors.initials: RM
authors.lastname: Darracott
authors.forename: Ricardo A
authors.initials: RA
authors.lastname: Hanel
authors.forename: William D
authors.initials: WD
authors.lastname: Freeman
authors.forename: Daniel F
authors.initials: DF
authors.lastname: Hanley
mesh_terms: D000328:Adult; D000368:Aged; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging* / Q000188:drug therapy*; D002552:Cerebral Ventricles; D003131:Combined Modality Therapy; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects; D023261:Glasgow Outcome Scale; D006801:Humans; D057967:Infusions, Intraventricular; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020521:Stroke / Q000000981:diagnostic imaging / Q000188:drug therapy; D015912:Thrombolytic Therapy / Q000009:adverse effects* / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014696:Ventriculostomy
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator