Treatment of Intraventricular Hemorrhage with Tissue Plasminogen Activator

Abstract

TEN PATIENTS WITH intraventricular hemorrhage (IVH) were treated with recombinant tissue plasminogen activator (rt-PA) injected directly into the lateral ventricles, followed by ventricular drainage. All had a decreased level of consciousness before treatment (Glasgow Coma Scale score 10 ± 3.4). A total dose between 2 and 12 mg of rt-PA (6.4 ± 3.3) was administered. For eight patients with aneurysmal IVH, treatment with rt-PA began with two patients the same day as the aneurysm clipping, and the day after with six patients. For a patient with an excision of a ruptured arteriovenous malformation and a patient with IVH resulting from a lateral ventricular catheterization during posterior fossa tumor surgery, treatment with rt-PA started 24 hours after surgery. After an injection of rt-PA, the ventricular drain was closed for 1 hour, followed by alternate-hourly drainage and intracranial pressure (ICP) monitoring. Five patients received a second injection of rt-PA on the second postoperative day, and one patient received a third dose on the third day. Among the eight patients given rt-PA the day after surgery, the volume of external cerebrospinal fluid (CSF) drainage for 24 ± 8 hours before treatment was 61 ± 57 ml, and the mean ICP was 22 ± 5 mm Hg during this same time. Younger age and poorer neurological condition correlated with higher ICP before treatment. After the initiation of rt-PA treatment, daily CSF drainage increased significantly (P < 0.005) and daily ICP decreased significantly (P < 0.005) as follows: 179 ± 66 ml and 16 ± 6 mm Hg during the first post-treatment day; and 168 ± 84 ml and 13 ± 6 mm Hg during the second post-treatment day. The number of days from IVH until the majority of clot cleared from the various ventricles (as determined by computed tomography) were as follows: lateral ventricles, 4.6 ± 1.8 days; third ventricle, 3 ± 0.5 days; and fourth ventricle, 3.5 ± 1.4 days. There were no hemorrhagic, infectious, or other complications resulting from treatment, and no catheter became obstructed with blood clot. Four patients ultimately required ventriculoperitoneal shunting. Outcome was severe disability in one patient, moderate disability in three, and no disability in six. Combined with early surgery to obliterate the source of bleeding and overall aggressive management of selected poor-grade patients suffering from IVH, intraventricular fibrinolysis with rt-PA appears to facilitate the rapid resolution of IVH, the continuous patency of the ventricular drainage catheter, and the normalization of ICP, and it may have a favorable effect on outcome.